Facility Evaluation Report

On 1-29-25 at 3:40pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct a quarterly health and safety visit. LPA met lead caregiver Melba Picardo and explained the purpose of the visit. Administrator Lourdes Fernandez was made aware of visit and purpose, and gave permission for lead caregiver to sign in her absence. LPA conducted brief interview with Administrator during today's visit and reviewed facility file documentation including LIC 500, physician's report for resident1 (R1), and individualized program plan (IPP) for R1.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. LPA observed Administrator on duty and an additional staff on duty. Administrator departed prior to completion of this visit. LPA also observed six residents with staff providing needs as appropriate.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 73*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished.

Review of LIC 500 revealed Administrator is on duty 33 hours per week instead of the 40 hour per week requirement as set forth by the Department on 11-5-24 during a previous informal meeting. LPA observed physician's report and IPP for R1 have been updated and pending final signature of appropriate parties involved.

As a result of today's visit, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with lead caregiver and a copy of this report was provided. Appeal rights provided.