Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to continue the annual inspection started on 7/30/2025. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Teresita "Roxie" Roxas .

The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 1 of which may be bedridden in a room with a direct exit. The facility has a waiver for 4 hospice residents. During today’s visit, the facility had a census of 6 non-ambulatory residents. The Administrator for the facility is Teresita Roxas and their certificate was valid and current.

During visits on 7/30/2025 and 8/8/2025, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. LPA observed an enclosed area located in the facility garage that the Administrator stated were two staff rooms. The Administrator stated that the area was an Accessory Dwelling Unit (ADU) and did not require a building permit due to its size. LPA was able to observe one of the rooms to contain a bed. Administrator stated that staff would use the rooms as a break area or to sleep after long shifts. The facility’s water temperature was measured at 106.7 and 107.6 degrees Fahrenheit in bathrooms for resident use. The facility’s internal temperature was measured at 76 degrees Fahrenheit. LPA observed an unlocked cabinet located in the backyard that contained cleaning chemicals and staff stated the cabinet was usually locked. Staff locked the cabinet prior to the end of the inspection.