Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with House Manager (HM) Maria Smith. Upon arrival, staff Sisay Ambaye (S1) took LPA temperature and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. COVID posters were observed at the main entrance and in facility. 2 staff and 5 residents were observed in facility.

LPA toured the facility inside out with HM. LPA inspected living room, kitchen, dinning area, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked. There are 3 shared rooms for residents, and 2 restrooms in facility. Beds in shared bedrooms were observed 6 foot apart. Some paper towels were observed without holders, S1 put the paper towels with holders in kitchen and restrooms. Cloth towels were observed in restrooms and kitchen. HM removed the cloth towel in restrooms and kitchen. Trash cans were observed with covers. There were no washing hands for 20 seconds posters by the sinks in restrooms and kitchen. HM put the washing hands for 20 seconds posters by the sinks in restrooms and kitchen. Room temperature was observed at 68 degree F, and hot water temperature was observed at 108 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient. PPE supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. HM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 10/06/2021. LPA inspected the backyard, there was no obstruction to block the walkway. HM stated all staff and residents are fully vaccinated and done with booster.

No deficiency or issue noted during inspection. Exit interview was conducted with HM. This report was provided to HM for signature.