Facility Evaluation Report

On 7/16/2025, Licensing Program Analysts, Kimberly Viarella and Arvin Villanueva (LPAs) arrived unannounced at this facility to conduct their annual inspection visit. LPAs initially met with staff on duty (S2) and stated the purpose of the visit. The Administrator Beatrice Clark (S1) was notified and arrived later.

Overview : Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents. 5 may be non-ambulatory. Bedrooms 1, 2, 3 and Master bedroom approved for non-ambulatory. Bedroom 4 approved for ambulatory only. Facility has hospice waiver for 2 residents.

Initial Observation: Upon arrival, LPAs observed 3 residents having their morning meal at the dinning table. Present during this visit were 6 residents in care with 1 staff on duty (S2). There was an outside agency staff assisting one resident. The room temperature was at 72 degrees Fahrenheit.

Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 5 resident bedrooms. Master bedroom is occupied by 2 residents. Bedroom #4 is currently being occupied by a non-ambulatory resident. LPA measured the hot water temperature in the 1 of 2 bathrooms to be at 107 degrees Fahrenheit. The light switch in the hallway bathroom was observed to be in disrepair. Also inside the hallway bathroom, LPAs found scissors under the sink cabinet, unlocked and accessible to residents in care. The bathroom inside the master bedroom, LPAs found a disinfectant spray inside the sink cabinet that was unlocked and accessible to residents. Also inside the bathroom in the master bedroom, LPAs observed the shower area to not equipped with grab bars. The master bedroom bath also has a closet which contains 2 Hoyer lifts.