Facility Evaluation Report

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct an annual licensing inspection. LPA identified herself to Administrator Ambalada of Gate Manor III, was granted entry, and explained the purpose of the visit. Gate Manor III is licensed to serve six (6) residents, all of whom may be non-ambulatory, four (4) may be receiving hospice services, and one (1) bedridden, During today’s visit, the current census was five (5) residents: three (3) receiving Hospice services, and two (2) non-ambulatory. The facility was operating within its licensed capacity and conditions.

An overall inspection of the facility began today; however, due to time constraints, LPA was unable to complete the visit and will return at a later time to conduct the remaining portion of the inspection.

No deficiencies were cited during today’s visit. This report was discussed with Administrator Ambalada. A copy of the report and Licensee Rights (01/2016) will be provided at the conclusion of the visit, and signature on this form acknowledges receipt of both the rights and this report.