Facility Evaluation Report

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Comprehensive Annual Visit as deemed during the NCC on 4/02/2025. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Licensee Victoria Legaspi, and discussed the purpose of the visit.

According to the facility’s license, there may be a maximum of six (6) residents, all of whom may be non-ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is 4 residents living at the facility. There were 4 residents present at the facility site during the inspection, but one left during the visit.

LPA, accompanied by Licensee Legaspi, toured the interior and exterior of the facility and inspected each room. The facility was clean 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. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities.

The facility’s ambient internal temperature was comfortable. Hot water temperature at taps accessible to residents were also compliant: sink in restroom #1 delivered hot water at 116.2 degrees Fahrenheit; and sink in restroom #2 delivered hot water at 119.5 degrees Fahrenheit. Staff also had an assigned bathroom #3 and delivered hot water at 122.4 degrees Fahrenheit, and according to the Licensee, residents do not use the staff bathroom. There was a cautionary sign posted. The kitchen sink measured hot water at 120 degrees Fahrenheit. Licensee said the residents do not use the kitchen sink.