Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required Annual Visit and met with Kourosh "Corey" Ebadat.

During visit, LPA Marrufo toured the facility inside and out.

LPA Marrufo toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA reviewed the first aid kit and found it to be complete.

LPA toured three out of three resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks ranged from 106 F to 118 F.

LPA tested the smoke detection system and it functioned properly when tested. LPA tested the carbon monoxide detector and it functioned properly when tested. LPA toured six out of six resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas.

LPA toured the outside area of the facility. The outdoor exits were clear of obstructions.

LPA reviewed the resident record, including the Centrally Stored Medication and Destruction Record, for 1 out of 1 resident and found it to be complete. LPA reviewed the Personal and Incidental Money Log for 1 out of 1 resident and found it to be balanced. LPA reviewed 3 staff records and found them to be complete.

See LIC809-C page for more information. Page 1 of 2.