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 by staff and explained the reason for the visit. Licensee/Administrator Lordele De Los Reyes arrived at 8:45am.

The facility is a 7 bedroom, 3.5 bathroom single story home with an attached garage. The facility is licensed for 5 non-ambulatory residents and 1 bedridden resident in room #6 only. The facility has a hospice waiver for 4 residents and currently has 2 residents on hospice.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and water temperatures. The water temperatures tested at 105 to 105.8 degrees. All smoke detectors were operational. The facility’s last fire drill was conducted on June 1, 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed 5 different food items that were expired dates ranging from September 2022 to April 2025 found in kitchen cabinets. LPA did not observe a PUB 475 in regulation size or facility license posted in the facility.

LPA reviewed 5 out of 5 resident files. LPA observed 5 out of 5 residents did not have a signed admission agreement. LPA observed 5 out of 5 residents did not have an appraisal conducted at admission or an updated appraisal. LPA observed 3 out of 5 residents did not have an updated medical assessment.