Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Lusanta Kaiyom, Licensee/Administrator.

During visit, LPA Marrufo toured the facility inside and out. LPA observed the kitchen area and the pantry area. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured the resident rooms. Each bedroom had working lights and available bedding. During visit, staff triggered the smoke detectors and carbon monoxide detectors in the facility bedrooms and hallways. All detectors functioned properly when tested.

LPA toured five resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathrooms ranged form 105 F to 119 F.

LPA toured the outside area of the facility and observed it to be clear of obstructions.

LPA reviewed six resident records, including Centrally Stored Medications and Destruction Records. All six resident records were complete. LPA reviewed six staff records. All staff records were complete.

See LIC809-C page for more information. Page 1 of 2.