Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Diana Natividad.

LPA observed 1 staff and 4 residents in the facility. LPA reviewed 3 resident files and 2 staff files. 3 out of 3 residents' appraisal needs and service plans over than one year, ADM stated the facility has updated appraisal needs and service plans and he/she will send to LPA. 3 out of 3 residents' centrally stored medication form were observed inaccurate.

LPA toured the facility inside out with ADM. License, ADM Certificate , and Personal Rights posters were observed in the facility. Family room, kitchen, dinning area and two restrooms were inspected. 4 resident bedrooms, 1 staff room, and garage were inspected. Two day perishable food supplies and seven day nonperishable food 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 114 degree F in the facility. The temperature of the freezer was observed at -1 degree F and the temperature of the refrigerator was observed at 37 degree F.

Fire extinguisher was serviced on 05/1/2025. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detector was tested by ADM, and as working. Front yard and backyard were inspected. There was no obstruction to block the walkways. Flash lights, first aid box, and night light were observed in the facility. the last time the facility conducted the fire drill was on 3/1/2025.

Deficiencies were noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.