Facility Evaluation Report

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by receptionist Samantha Barrientos. LPA discussed the purpose of the visit with Executive Director Bee Bee Smith.

According to the facility’s license, there may be a maximum of 80 residents, all of whom may be non-ambulatory at any given time at the facility site. The facility is approved for 15 bedridden and 20 hospice residents. During today’s inspection, the facility’s current census is 51 residents living at the facility, of whom 51 were present at the facility site during the inspection. The facility comprises three sections, which may serve residents with similar care needs.

LPA, accompanied by Executive Director Smith, toured the interior and exterior of the facility and inspected private shared, and individual rooms, kitchen, laundry, and maintenance areas. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings – chairs, lamps, drawers, etc. Doors, windows, toilets, and showers were in working order. LPA observed extra linens and hygiene supplies were present in the residents’ individual closets as well as the facility's linen closet. Personal Protective Equipment was present. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and activities.

The facility’s ambient internal temperature was comfortable and compliant, at 73°F. Each room had its own designated thermostat to adjust the temperature to the residents' comfort. Hot water temperature at taps accessible to residents was also compliant. Level 1: sink in a private room restroom #1 delivered hot water at 115.3°F; sink in a shared room in restroom #2 delivered hot water at 111.9°F;