Facility Evaluation Report

On 8/20/2025, LPA Grace Donato conducted an unannounced annual visit to the facility. LPA met with care staff Nenita Bactad & Edwin Bactad. LPA explained the purpose of the visit.

LPA toured the facility inside and outside. While touring the facility it was observed that the temperature was af 73 deg F. Hot water was also tested and temperature was within required range. The residents have adequate amount of incontinence care items. All personal belongings are intact. All fire extinguishers have been checked. Medication review was done and all medications are accounted for and centrally stored medication records are updated.

Gate exit is not opening properly and the exit door in one of the residents rooms has the walkway dilapidated and needed to be repaired.

Each resident rooms were checked. R4 and R5s room have walls that needs to be repaired. R6 & R4s bottom mattress needs to be changed due to deterioration. Rooms 1, 2 & 3 doesn't have a chair, light and night stand. Pillows need to be updated. Bathroom was observed to be in disrepair, wall above the mirror has molds forming, trash bin does not have a lid and toilet paper holder needs to be repaired. Paper towels are not present in the bathroom.

Six resident records were reviewed. 5 out of 6 does not have an updated needs and services plan. R4 does not have a medical assessment (602) and functional capabilities assessment forms. R3 and R4 does not have an updated medical assessment, residents being 60 above. 6 out of 6 residents do not have a safeguards for property and valuables forms.