Facility Evaluation Report

On 03/10/2028, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required annual 1 year inspection visit. LPA met with the Administrator Lei Bi and explained the purpose of today's visit. During today's visit there are 5 residents present and 1 is in the hospital due to illness. There are 3 staff present and the administrator.

This is a two level facility. Resident reside on the ground floor only. The second floor is housed only by staff at this time. There is a keypad locked door in the kitchen that leads to the second floor. This facility is licensed for 6 residents, 60 and over, whom all may be non-ambulatory. Hospice waiver on file for 2 residents. During today's visit there are 2 residents on hospice. LPA inspected the kitchen and found it clean, with breakfast preparation and cooking in progress at the time. Lunch was also being prepared for cooking. The appliances were checked and observed to be in working order. LPA inspected a locked cabinet containing knives and sharp objects below the cooking range. Resident medications are locked as well with resident files on a lower cabinet adjacent to the cooking range. The refrigerator and pantry cabinets are inspected as sufficient in supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted in the refrigerator. Dining table is in the kitchen. The large living room area is observed as clean, with all furniture in good repair. There was a sofa set and a television in the living room. LPA observed a fire extinguisher mounted on the wall adjacent to the living room are and found it fully charged, with the last service tag dated 01/21/2025. Facility has a hard wired combination smoke and carbon monoxide detector in the living room which is central to all resident rooms.