Facility Evaluation Report

On 8/14/2023, at 9:30 a.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Ronald Ramon Torio who was informed of the purpose of visit. Administrator May Embalsado arrived later during the visit and provided LPA with client and staff files previously removed from the facility.

During the visit, there was six (6) clients and three (3) staff present. The facility is approved to care for six (6) non-ambulatory clients, of which two (2) may be bedridden. LPA toured the facility’s interior and exterior. During the visit, LPA observed the following:

Bedrooms : Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Detectors/Fire Extinguisher: Carbon monoxide and smoke detectors were tested and functioning properly. Fire extinguisher is charged and mounted on kitchen wall.

Kitchen: LPA observed the facility did not have a 2-day food supply of perishable food items. LPA observed an unsecured knife and pair of scissors on kitchen countertop. LPA observed menu posted on the refrigerator based on the USDA Basic Food Group Plan – Daily Food Guide; however, LPA observations along with Staff and Administrator interviews revealed that the facility is not following the menu posted and the facility provides menu substitutions for Client #3 without consulting a facility dietitian, registered dietitian, physician or medical provider for Client #3's recommended 1500 calorie ADA diet. Three deficiencies were cited regarding the above-mentioned.