Facility Evaluation Report

on 7/8/25 at 9:45, Licensing Program Analyst(LPA) Noel Wolf Petersen arrived unannounced to conduct an inspection of conditions and care related to the PEG tubing resident and met with Christine Joy Arcega, a staff member, and explained the purpose of the visit. The facility is a Adult Residential Facility with a capacity of 5 clients and 5 clients currently in the facility, 1 non-ambulatory, and 4 ambulatory. A client with a restricted condition is currently working on an exemption for a peg-tube, no other restricted conditions are amongst the current population of clients.

A physical inspection was completed, including but not limited to common areas, exteriors, evacutation routes, kitchen, storage areas, the client bed rooms and bathrooms. Required furniture and furnishings of the bathrooms, bedrooms, and common areas are present and in good repair. The facility is well lit, and traffic areas are unobstructed. all required postings are present including the facility sketch, federal work rights, the vmrc rights poster, and the administrator certification and facility license. LPA pointed out the ombudsman poster has a particular dimension in the regulation, and the staff provided that it would be replaced. Sharps and medications were stored locked, and although some of the hand soaps and sanitizers were left out and could potentially present a hazard if consumed, no client currently in the facilities care is specifically unable to handle hygiene products unsupervised in their physicians report while being unsupervised in the bathroom. The staff provided it would still be prudent to switch to non-toxic soap. LPA observed one of the two indicated fire exits has a gate that is somewhat difficult to open due to dragging into the concrete and needs to be rehung. Staff noted some repair would be made, while pointing out the second gate was fine.