Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with Alejandra DeLuca, House Manager/caregiver, and stated the reason for today's inspection. Also Rebecca McFadden, Administrator. LPA observed (5) residents resting in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents, and has a hospice waiver for (2). Currently, there are no residents under hospice care. There have been many interior upgrades.

LPA and the Administrator toured the interior/exterior of the facility including the common areas, (2) shared resident bedrooms, (2) private resident bedrooms, (2) resident bathrooms, kitchen, laundry. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout. The bathrooms have the necessary grab bars, non-skid flooring, soap, paper towels, and a 20-second hand-washing sign will be posted at each sink. Hot water measured 110*F in the kitchen and inside temperature measured 69*F. There is sufficient 2+day perishable and 7+day non-perishable supply of food. Sharps and toxins are locked in the kitchen. Smoke/monoxide alarms are in working order. Quarterly disaster drills are being conducted. There are sufficient linens/towels/blankets and a complete First Aid kit. Required postings are visible in the common area. There are open exits in the backyard. Currently there is a patio project going on to add seating and flowers. Residents participate in art projects, movie, Bingo and pet therapy. LPA reviewed (2) resident files and (2) staff files. Files were organized, current and complete. Medications were reviewed for (1) resident, orders match medications being administered, and documentation is current. Staff is cleared/associated and completing the required initial/continuing annual training, including First Aid/CPR. Administrator RCFE #6013990740- exp 11/8/25. Discussed updated regulations. LPA requested an updated copy of liability insurance, LIC308 and LIC500 be submitted by 4/15/25. There were no deficiencies observed and no citations being issued. Exit interview. Copy of report provided.