Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Executive Director (ED) Carmen Galicia and explained the reason for the visit. Facility is licensed for 152 ambulatory residents, of which 96 may be non-ambulatory, with a hospice waiver for 30 residents, and 30 maybe bedridden on the first and second floor. Currently there are 116 residents and 13 are on hospice during today's visit.

LPA Tea reviewed twelve resident files and six staff files. Resident files and staff files contained all required documentation. Administrator's certificate is currently pending renewal due to the backlog processing. Administrator completed all course work and submitted renewal.

LPA Tea along with ED Galicia toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a three-story building. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. Last disaster drill was conducted February 10, 2026. LPA observed evac chairs in every stairwell in the facility for emergencies. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 116.4 to 118.6 Fahrenheit degrees. LPA pulled emergency pendants in resident’s bathrooms; staff came to the room to respond to the alert within four minutes. LPA also tested the push pendant that residents press for assistance, staff came within two minutes. Common areas were clean and clear of hazards; doorways were free of obstructions. Facility kitchen and dining area were inspected. Perishable and non-perishable food supply was checked