Facility Evaluation Report

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Patti Fesseha. During the visit, LPA observed 5 residents and 2 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 115 degrees F in both resident bathrooms.

While touring the home, LPA observed the family room, adjacent to bedroom #4. LPA observed the family room was being used as a bedroom. ADM stated she is having a resident stay there and did not notify the Department of the change of use of this room. (Photographs were taken). While touring the backyard, LPA observed a sliding screen door installed in bedroom #4 and the family room adjacent to bedroom #4. ADM stated stated these changes were done sometime in February 2024.

LPA requested to review the facility fire/earthquake drill log. The facility's last drill was on September 31, 2024. LPA observed the fire drill for the fourth quarter had already been signed, for December 31, 2024. ADM stated it was a typo and the drill was conducted in December 1, 2024. LPA requested ADM conduct another drill for the month of December and send LPA documentation that the drill had taken place.