Facility Evaluation Report

On 04/11/2024 at 08:45 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were three (3) staffs present, and five (5) residents present. Licensee/Administrator Milagros Azaula was contacted and informed of the visit. Licensee/Administrator Milagros Azaula arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Milagros Azaula.

The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room, laundry area and a garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents, one (1) may be bedridden. The facility has six (6) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Staff #2 (S2) to conduct a general overall inspection, which included, but was not limited to the following:

Physical Plant : The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space and with sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms.

However, LPA Brown observed Resident #5 (R5) with half bed rail and no written order from R5's physician indicating the need for half bed rail for mobility. Deficiency will be issued.