Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual and met with Rosana Mead, Administrator. Caregiver Rowena Tirasol, and maintenance staff, Thaddeus Tirasol, were also present. LPA observed (1) hospice personnel present and a second hospice staff arrive during the inspection. LPA observed (1) resident eating breakfast in the common area. The facility is licensed for (5) non-ambulatory residents (1) of whom may be bedridden, (1) ambulatory and has a hospice waiver for (3). Currently, there is (1) resident on hospice.

LPA and Administrator toured the interior/exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom, (2) resident bathrooms, (1) staff room, kitchen and laundry/office area. LPA observed the facility to be clean, in good repair and odor-free. Bathrooms have the necessary grab bars, skid-resistant flooring and hygiene supplies. There is sufficient 2+ day perishable, including fresh produce, and 7+ day non-perishable supply of food. Sharps, medications and toxins are locked in the kitchen/laundry area. The inside temperature measured 71*F, and hot water measured 115.5*F in a resident bathroom. Smoke/monoxide alarms are working and the extinguisher was last serviced 5/13/2025. Administrator to ensure all exit doors have functioning auditory alerts, including vacant resident rooms. There are (2) unlocked gates and there are no blockages to exit doors. First aid kit is complete.

LPA reviewed (2) resident files and (3) staff files. Files were organized and contained current documentation. Administrator certificate is pending renewal- exp 3/18/26. Staff are completing required continuing training. All staff have current 1st Aid/CPR and are cleared/associated. Required postings in the common area. An updated copy of the LIC308, LIC500 and current liability insurance were obtained. There are no deficiencies issued. Exit interview. Copy of report provided.