Facility Evaluation Report

Amended Version - updated 6/30/26 due to incorrect date noted for the fire extinguisher.

Licensing Program Analyst (LPA) Rankin arrived at 9:18 am and made an unannounced 1-year required annual visit to the facility above. LPA met with Amelita Antonio and Juanito Pasion, both Administrators for the facility homes and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on 2/25/2026. Fire sprinkler system was last inspected in June of 2025, it is due for it’s annual inspection this month. The facility has 5 bedrooms and 2 bathrooms currently occupying 6 residents. The facility has smoke and carbon monoxide detectors that were tested and working at time of visit. The lighting is sufficient for the use of the facility and for resident comfort. The toilet, hand washing and bathing facilities are operational and secure grab bars are present. The showers have non-skid mats and/or flooring. The pathways are clear of any obstructions. Disinfectants and cleaning solutions are inaccessible to residents in care. The facility has sufficient space inside and outside for activities and visiting.

Operational Requirements: The facility has current liability insurance that expires on 12/30/26. The facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6. Fire clearance is granted for 6 bedridden residents. A hospice waiver is approved for 2 residents.

Staffing Records and Training: The facility currently employs 7 staff, 5 are full-time caregivers, and 2 are administrators, if needed more staff can be pulled from other facilities nearby. Files reviewed had required documentation including but not limited to 1st Aid/CPR, Health screening with TB results, and Criminal Record statements. Administrator’s Certificate expires 1/16/27. Staff have annual training completed for various subjects/topics and hours for 2025 and 2026. Continued 809-C