Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Elsie Casumpang. Upon arrival, HM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with HM. COVID posters were observed at main entrance and the facility. No screening station at the main entrance, but masks, hand sanitizer, glove, thermometer and visitor log book were observed at living room and dinning area. HM stated the facility will setup a screening station at the man entrance in 3 days. Living room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towel were observed with holders. Three resident bedrooms were inspected. One staff live-in room is in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 106 degree F in facility. One residents was observed in facility.

Fire extinguisher was serviced on 4/29/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Front yard and backyard were inspected. There was no obstruction to block the walkways.

HM stated all the residents and staff are fully vaccinated and done with booster. No citation were noted today. Exit interview was conducted with HM. This report was provided to HM for signature.