Facility Evaluation Report

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Facility Manager Alicia Millan. The facility was licensed for a capacity of six (6) non-ambulatory residents, and had an approved hospice waiver for three (3) residents.

Accompanied by Millan, the LPA toured the interior and exterior of the facility, and inspected bedrooms. The facility

was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens

and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, and safely stored.

Cooking equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents.

Medications were labeled and stored in a locked area.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. A carbon monoxide detector, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were also present. Required licensing postings were observed in visible areas of the facility.

The LPA conducted an interview and reviewed multiple staff and resident files. A deficiency for missing staff health screenings was cited in an LIC 809D form. A Plan of Correction (POC) was jointly formulated with Facility Manager Alicia Millan.

An exit interview was conducted with Millan, to whom a copy of this report, LIC 809D, LIC 811, and the Licensee/Appeal Rights (LIC9058), were provided.