Facility Evaluation Report

Licensing Program Analyst (LPA) Rankin arrived at 8:29 am to conduct a 1-year annual visit to the facility above. LPA met Administrator Allan Sepulveda 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 facility is a 6 bedroom and 4 ½ bathroom, with 1 bedroom and ½ bathroom dedicated to staff. The facility occupies 6 residents and employs 3 full-time staff of which one is the Administrator, and one is a live-in staff. Facility has 3 on-call staff if needed. The facility is clean, safe and sanitary. The facility has smoke and carbon monoxide detectors which were tested and working properly during the visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Disinfectants, cleaning solutions and poisons are stored under kitchen sink and in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with furniture and plenty of shade. The backyard has 3 locked sheds to store extra furniture and items.

Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance based on the facility sketch. The facility has current liability insurance and expires on 03/20/2026, the updated form will be emailed to LPA at the end of the week when the renewal document is received. The facility is approved for a capacity of 6 non-Ambulatory and approved for hospice waiver of 6. Continued 809-C