Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit.

The facility is licensed for 15 non ambulatory residents. The facility has a hospice waiver for 8 residents.

The facility is a two-unit one-story house each as unit A and Unit B. Unit A has 4 resident bedrooms, 1 staff bedroom, 2 full bathrooms, a living room, a dining room, and a kitchen. Unit B has 6 resident bedrooms, 1 staff bedroom, 3 full bathrooms, a living room, a dining room, and a kitchen.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperature in the bathrooms. The hot water temperature in Unit A measured 114.4 and 115.7 degrees Fahrenheit and all smoke detectors were operational. The water temperature in Unit B measured between 117.9 to 133.5 degrees Farenheit. The facility conducted an emergency drill on June 2025. LPA inspected the facility food supply for both Unit A and Unit B and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed seasonings that were expired in Unit A's kitchen. LPA observed secured medication storage in a secured cabinet for both untis. LPA observed emergency food and water in facility laundry room. LPA observed Resident 9 (R9) had full bed rails without hospice. LPA observed R9 LIC 602 Physician's Report that is out of date.

LPA reviewed six out of six staff training and fingerprint records and conducted a complete review of 12 out of 12 residents files. Administrator has a current administrator certificate which expires on 08/24/2027.