Facility Evaluation Report

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Lilia Claur. Licensee, Julie Verzosa and Administrator Edgar Verzosa Jr. arrived during the visit.

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 118 F..

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. During the tour, LPA observed a padlock on the side entrance. Staff explained they use the padlock at night for safety but forgot to remove it this morning. Licensee, administrator, and staff were all made aware a padlock is not allowed, as it's a fire safety violation. The lock was removed during the visit. Staff agreed to no longer use a lock on the exterior gates.

No pools or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files contained required documents. Confidential records were stored in locked areas.

A deficiency was observed and cited during today's annual inspection, along with an immediate civil penalty for a fire clearance violation. An exit interview was conducted with Administrator Edgar Verzosa Jr. to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.