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 Licensee Rathi and was granted entry into the facility. The facility is licensed for six (6) residents;of which all can be non-ambulatory, 1 resident may be bedridden, and 3 may be receiving Hospice services. During today's visit all 6 residents were present.

LPA Correia conducted a resident records review and conducted a partial facility tour. An overall inspection of the facility began today however due to time constraints LPA was unable to complete the visit and will return later to conduct the remaining portion of this inspection.

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