Facility Evaluation Report

REPORT AMENDED TO RESCIND DEFICIENCY AND CIVIL PENALTY. LPA met with Gary Baldoza during this visit.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/8/23 at 10:00AM. LPA met with Caregivers Ermenia Pascual Domingo and Andres De La Cruz Bayang who contacted the Administrator Marina Baldoza regarding the purpose of todays visit. Marina Baldoza arrived at 12:00pm to assist with todays visit. The Administrator Certificate was observed for Marina Baldoza which expires 8/16/24.

LPA observed a receipt that indicates on 9/28/23, the Licensing fees were paid in the amount of $495.00.

The facility is licensed for a capacity of 6 non-ambulatory residents of which 2 may receive hospice care services. There are 0 residents receiving hospice services at this time. LPA was provided a copy of the approved, signed, hospice waiver for 2 during this visit.

LPA observed residents and conversed with them during this visit.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 117.1*F which is within the required range of 105-120*F.

LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 3 staff and 2 resident files and conducted interviews during this visit. LPA did not observe a first aid/CPR certificate for the 3 staff during this visit.