Facility Evaluation Report

At 9:30am on 08/18/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Administrator, Guillerma Pacaoan, announced who he is and the reason for the visit.

Administrator and LPA conducted a full tour of the facility inside and outside. LPA noted that this is a 4 bedroom and two bathroom facility, One bedroom is designated for dual resident occupancy and the other two rooms are for single resident occupancy, the other room is staff only room. There are 2 bathrooms, one designated for residents the other designated as staff only. There is a breezeway where the washer and dryer are located there is a large living room, and large dining seating area, and a kitchen. There is a covered porch that wraps around the back and side of the facility that provides seating and shade for residents and visitors. LPA noted that each room is furnished per licensing regulations. Both bathrooms have paper towels and liquid soap. Water tested in both bathrooms and kitchen, all to be within licensing regulations temperature (105*-120* (f)). LPA noted that there is a fire extinguisher in the dining room that is primed and in the green. LPA tested all smoke detectors and carbon monoxide detectors to be working and were tested during facility annual inspection. LPA tested hardwired smoke detector and CO2 alarms working throughout the facility. LPA noted that the medications and files are locked in the dining room area in locked cabinets. LPA noted that there is a complete first aide kit. LPA noted that the door ways and passage ways in the facility were free and clear of obstacles and debris. LPA reviewed all staff and resident files all to be completed and training up to date. LPA reviewed emergency disaster plans and emergency drill logs. LPA conducted a review of Centrally Stored Medication Records (CSMR) and found no errors. LPA conducted a full review of the annual care tool modules. During this annual facility inspection LPA observed lock to cabined containing clearing solution unsecured and issued a single citation for this facility annual inspection.

There no other violations or citations as a result of this facility annual inspection.

Exit interview, report read, citation issued, appeal rights and report provided.