Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon arrived at 11:50am to conducted a 1 year annual visit to the facility above. LPA met with Staff Paraluman Tatsuo, whom called Administrator. Administrator Abiy Tesfazgy arrived shortly and LPA explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) initially and annually thereafter.

Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 12/01/2025. The facility is approved for a capacity of 6 with 6 Non-Ambulatory. Hospice approved for 2.

Physical Plant & Environmental Safety: The facility is a 4 bedroom and 2 bathrooms currently occupying 3 residents and employs 3 full time staff and 1 Administrator. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has an fenced backyard for client use with plenty of shade. The gate on the sides of house are self closing and self latching. The facility has telephone and internet service for resident use. Continued 809-C