Facility Evaluation Report

Licensing Program Analyst (LPA) Rankin arrived at 10:02 am to conduct a one-year annual visit to the facility above. LPA met with Back-Up Administrator, Cheryll Estacio and 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:

Physical Plant & Environment Safety: The facility has 5 resident bedrooms, 2 bathrooms and currently occupies 5 residents. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were tested and working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats or textured bottoms. A schedule for resident’s showers was posted on the refrigerator door. All residents require assistance in bathing so a plan to ensure all residents received their showers is tracked. 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 under sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard, LPA requested updates to the gate on the right front facing side of the facility to ensure it self-closes. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on 01/07/26. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory of which four may be bedridden. Hospice is approved for four.

Staffing: The facility currently employes four full time staff and two Administrators. Staff files were reviewed. LPA observed recent Health Screening done on 1/6/25 that stated “able to provide assistance without significant lifting/pushing/pulling” done for two staff, administrator will need to assess the support required to ensure the safety of residents in care. Current Administrator Certificate expires June 18, 2026.