Facility Evaluation Report

On 8/15/2025, Licensing Program Analyst (LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Administrator/Licensee, Nelia Asuncion and explained the purpose of the visit.

LPA Calandra toured the physical plant. This is a 1-story building with 4 bedrooms, 2 bathrooms, kitchen with dining, and living room. No accessible bodies of water or hazards were observed. The fire extinguisher was fully charged. The smoke detectors were observed to be fully operational. All bedrooms had the required furniture and sufficient lighting. The facility's hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility had the required 7-days of non-perishables and 2-days of perishables items. No food was expired. The facility's first aid had all of the required items.

Sharp objects, soap, detergents, and poisons were observed to be accessible to persons in care.

LPA reviewed 3 resident files and 2 staff files. All were observed to be complete.

Medications were reviewed and found to match Centrally Stored Medication Records kept at the facility.

During the inspection, LPA observed during file review that neither the Licensee/Administrator had active First Aid and/or CPR certificates. A Type A citation was provided for this deficiency.

In addition, during file review, LPA observed that the facility had not conducted an Emergency drill since March of 2024. A Type B citation was provided for this deficiency.