Facility Evaluation Report

On 04/05/24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit.

1. Conduct mandated reporting training in 6 months (Aug) then annually (Feb)

2. Conduct personal rights training by 03/01/24 then again in Aug then annually (Feb)

3. Administrator present 20 hrs week at each facility

4. Conduct Staff training occurs monthly regarding IPPs

Administrator states TSP has been completed. A copy of the training documents were provided to LPA Lewis. Licensee is out of the country until 11/26/24. Estela Gapasin will be filling in for the 20 hours a week that is required.

The LPA conducted a tour of the physical plant and observed the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations.

Based on interviews, file reviews and observation of the physical plant, it appears the facility is operable at this time.

An exit interview was held with Estella Gapasin and a copy of the report was provided.