Facility Evaluation Report

Unannounced Annual visit made out to this facility on 07/07/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Sheryl Bravo, who was briefly interviewed at this time.

It was learned that there were (10) residents under the care of hospice at this time while other residents were receiving services through home health as well.

This facility does have a hospice waiver approved for (25) residents and does have a program on file to address dementia care for residents at any given time.

It was learned that there were (4) residents deemed to be bedridden at this time. This facility does have a fire clearance to be able to accept/or retain up to (10) residents deemed to be bedridden at this time.

Administrator certificate was observed to be present for facility designated Administrator Sheryl Bravo. The expiration date was set for 03/03/2024. All documents have already been submitted to renew at this time.

Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured.

Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time.

A tour of the dining area, living area, and all other areas intended for resident use was conducted.

Medication rooms, located on each floor, were reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time.