Facility Evaluation Report

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA identified herself to Caregiver Euben and explained the purpose of the visit. The facility is licensed to six (6) residents of whom five (5) can be non-ambulatory, one bed-ridden, and 5 receiving hospice services.

During today’s visit, LPA Correia conducted an interior and exterior tour of the facility and resident and staff records reviews. LPA also briefly spoke to a resident in care and interviewed facility staff. The facility's physical plant and staff and resident records were observed to be in compliance. One deficiency was observed and cited during today's annual inspection.

An exit interview was conducted with Caregiver Euben to whom a copy of this report and deficiency statement (LIC 9099 and LIC 9099D) and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. Signature on this form acknowledges receipt of the rights and a copy of this reports.