Facility Evaluation Report

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Marivel Johnson. The facility's license shows a maximum capacity of 249 residents, 85 of whom may be non-ambulatory. Additionally the facility is approved for twelve (12) hospice waivers. During today’s inspection there were 222 residents in care. Note, LPA did step out for lunch from 12-1pm.

LPA, ED Johnson, and Director of Environmental Services Arturo Vega toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at sampled taps accessible to clients were all compliant: Bathroom sink in a unit of the Villas building was read at 105.6F and water temperature in a bathroom sink of the Casa Loma building read at 106.8F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. The facility is about to undergo a remodeling of their main kitchen and a temporary mobile kitchen was developed and will be used during construction.