Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Fay Cacdac. Upon arrival, ADM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at main entrance and the facility. Screening station with mask, hand sanitizer, glove, thermometer and visitor log book were observed. Living room, family room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towels were observed all with holders. Four resident bedrooms, laundry room, and garage were inspected. 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 69 degree F, and hot water temperature was at 120 degree F. Four residents were observed in facility.

Fire extinguisher was serviced on 05/05/2022. The facility was equipped with smoke and carbon monoxide detectors. Fire alarm system was tested, and was working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated with Pfizer. ADM already submitted Infection Control Plan to LPA. No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.