Facility Evaluation Report

On 4/17/2025 LPA Grace Donato conducted an unannounced annual visit to the facility. LPA met with Administrator Shayan Gheisar and explained the purpose of the visit.

LPA toured the facility including a random sample of resident rooms, common areas, and kitchen . LPA observed some residents were at the dining room having breakfast. While touring the facility it was observed that the temperature was at 69 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitor is working properly. All fire extinguishers is due for April evaluation. Facility has a scheduled maintenance for these extinguishers on 4/17/2025. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Food supply delivery is scheduled on this day. Emergency drills are done quarterly.

Six resident records and six staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Administrator certificate has expired but renewal has already been submitted and pending evaluation. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Hot water was tested in random rooms and 7 out of 9 showed a temperature of between 99-103 deg F.

During the review of staff roster, it was found out that 4 staff members does not have criminal background clearance.