Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee/Administrator Lilia Rena.

According to the facility’s license, the facility has a maximum capacity for six (6) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of four (4) residents in care, of whom one (1) was ambulatory and three (3) were non-ambulatory, but none were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeters, and none of these were present.

LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected all common areas and resident bedrooms. LPA interviewed multiple residents and multiple staff. LPA reviewed care records for all residents and personnel records for all active staff. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 74 F. Where tested, hot water temperature at taps accessible to residents were all compliant: Kitchen Sink was 113 F, Bathroom #1 Sink was 112.5 F, and Bathroom #2 Sink was 114.1 F.