Facility Evaluation Report

Licensing Program Analysts (LPAs) Jacqueline Shaw Ross and Kyle Wellington conducted an unannounced visit to the facility for the purpose of an annual inspection. LPAs was greeted by caregiver Bruna Siadto and explained the purpose of the visit. A tour of the facility was conducted inside and out. At the time of visit, there were three (3) residents home and two (2) staff present. Administrator Kristin Chua arrived shortly.The facility serves six (6) non-ambulatory elderly residents; ages 60 and above, of which two (2) may be bedridden, and is approved for a hospice waiver for six (6).

The facility is a five (5) bedroom one story home. One (1) bedroom was observed to be empty, three (3) bedrooms were private occupied, one (1) bedroom was designated for staff. The facility has two and one-half bathrooms.

During the tour the following was observed: Residents bedrooms had the required furnishings and were observed to be in good condition. Upon observation of one of bedroom one (1), LPAs observed the residents' private bathroom and closet being used for storage items that did not belong to resident. DEFICIENCY CITED .

Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous chemicals are locked and inaccessible to residents. Hot water was tested and measured 117 degrees.