Facility Evaluation Report

On October 23, 2021, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced annual inspection. When LPA arrived to the facility, the staff and resident's were receiving their booster shots. LPA observed COVID-19 signage on the front door and side door. LPA met with Administrator, Russlynolg Guevarra and Licensee, Fatollah Ghlichloo joined shortly thereafter. LPA Charitra explained the purpose of the visit and was screened at the designated entrance.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, resident and staff daily monitoring records, visitor screening log, and 30-day PPE supply. Administrator was able to provide screening log documentation for residents, visitors, and staff.

LPA observed two bathrooms, both equipped with liquid hand soap, paper-towels, and a covered trash bin. LPA advised Administrator to not keep any hand towels or bath towels in the bathroom or kitchen. LPA observed three single rooms, all of which are occupied at this time. LPA observed clean linen present in each resident room.

COVID-19 signage are posted throughout the facility such as social distancing, face covering, cough etiquette, and COVID-19 symptoms. LPA observed the living area to have chairs distanced 6ft apart from one another to maintain social distancing.

Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. 2-day perishable and 7-day nonperishable food supply was present.

The following forms are requested to be submitted to LPA by 11/5/2021 :

The report is reviewed with Administrator and a copy is provided. No citations issued.