Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Remedios Inocencio.

The facility has a licensed capacity of 6 non-ambulatory residents and has a hospice waiver for 2 residents. During today’s visit, the facility had a census of 5 residents, 4 were non-ambulatory. The Administrator for the facility is Remedios Inocencio and their certificate was valid and current. During today’s visit, LPA inspected each room of the facility, including resident rooms, private and common bathrooms, kitchen, garage, common areas, and outside space. No bodies of water, delayed egress, or secured perimeter were observed on the premises. The facility was found to be clean, safe, and in good repair. LPA observed linens and hygiene products for resident use. The facility’s ambient temperature was measured within regulatory requirements. The hot water temperature in private and common bathrooms were measured at 124.0 and 128.7 degrees Fahrenheit. Administrator turned down the hot water heater during the visit. LPA observed locked storage for resident medications and hazardous and/or toxic chemicals, both of which were stored separately from food supplies. According to Remedios Inocencio, no firearms or weapons are stored on the premises. LPA observed a minimum supply of 2-days of perishable food and 7-days of non-perishable food. The refrigerator and freezer temperatures were kept within requirements. Staff present at the facility had a criminal background clearance and association. LPA reviewed multiple resident and staff records.

The following deficiency was cited for water temperature and noted on the attached LIC809-D page. Additionally, an LIC9102TV Technical Violation regarding evacuation drills and LIC9102TA Technical Advisories regarding resident annual visits and facility maintenance were provided. An exit interview was conducted with Administrator Remedios Inocencio, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).