Facility Evaluation Report

On 6/19/2026, Licensing Program Analyst (LPA) Reza Jamaly and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced at this facility to conduct required 1 year visit. LPA met with the Staff 1 (S1) Marvin Rodriguez and stated the purpose of the visit. Administrator (A1), Annie Lyn Rodriguez later arrived and assisted with facility tour. There were 6 residents in care, 5 present and 1 in hospital with 2 staff on duty.

The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 maybe bedridden in Room 3, Hospice waiver granted for three but there is only one resident on hospice in Room 4. During this visit

Administrator certificate was observed to be expired on 6/2/2025 per, administrator application for renewal submitted on March 25, 2025 but no update has been received as of today. LPM sent an email to Administrator Certification Bureau to follow-up on the application status since the A1 provided proof to LPM and LPA that the application was submitted with a check in the amount of the required fee.

LPA and LPM toured the facility including but not limited to the common areas, kitchen, dining area, resident's bedrooms, bathrooms, laundry room and outdoor ground of the facility to ensure compliance with Title 22 regulations. LPA and LPM observed the facility to be free of odor, clean and in good repair. LPA and LPM observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA and LPM toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Refrigerator temperature was measured 30 degree Fahrenheit and Freezer temperature measured to be 20 degrees which is not in range of below 0 Degree as outlined in regulations. LPM observed one head of cauliflower in a plastic wrap to have beginning stages of mold on it. LPM asked facility staff to discard the item immediately and staff threw away the item immediately.

Hot water temperature measured 111.7 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. Hot water temperature measured 109.4 degrees in common area bathroom sink, which was within required range as well. Room temperature during this visit was measured at 71 degrees Fahrenheit.