Facility Evaluation Report

Licensing Program Analyst (LPA) David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by Bao Thi Tu, Administrator, and identified himself to, and discussed the purpose of the visit with them. According to the facility’s license, the facility has a maximum capacity of four clients, of whom two may be non-ambulatory.

LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications will labeled, as required, and stored in locked areas. Water temperature was measured at 120 degrees F.

No pools or bodies of water on the premises. Per Bao Tu, no firearms or ammunition are kept at the facility. Carbon monoxide and smoke detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible.

An exit interview was conducted with Administrator, Bao Tu, to whom a copy of this report and the Licensee/Appeal Rights and were provided during the visit. Their signature on this form acknowledges the receipt of this report and their rights.