Facility Evaluation Report

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Licensee Gus Fernandez. The facility's license shows a maximum capacity of six (6) residents, one (1) of which may be bedridden. Bedridden may only reside in bedroom #2. Additionally the facility is approved for 2 hospice waivers. During today’s inspection there were three(3) residents in care.

LPA and Licensee toured the interior and exterior of the facility and inspected each room. 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, screens, toilets, and showers were in working order. Hot water at taps accessible to residents were all in compliance. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and residents, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. [Cont. on LIC 809-C]