Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 12/1/23 at 2:00pm. Administrator Certificate expires 1/30/25. Licensing fees are current.

LPA met with Cynthia Cruz-Maduro, Administrator and Hoey Cruz, Caregiver and stated the purpose of todays visit. The facility is licensed for a capacity of 4 ambulatory residents of which 1 may be non-ambulatory. LPA observed 1 resident non-ambulatory during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 105.1*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the P&I monies for resident #1 (R1) to be correct and documented and not commingled during this visit.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 staff and 2 resident files and conducted interviews during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:

Designation of Facility Responsibility (LIC308), Personnel Report (LIC500), Administrator Certificate-Updated, any updates to Infection Control Plan

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited. Exit interview held, copy of report given