Facility Evaluation Report

Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection and was greeted by licensee Lilia Saddi. Facility is a Residential Care Facility for the Elderly that has a fire clearance approved for six residents in which four can be ambulatory and two non-ambulatory. Approved hospice waiver for two residents. Upon arrival, LPA observed staff (S1) was fingerprint cleared but was not associated to Guardian Roster (Deficiency cited, see 809D)

LPA and admin toured the building and grounds which was found to be clean and in good repair. Facility was clean and at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. All required postings were in a highly visible area. Fire extinguishers were charged and last inspected 2/03/2025. Fire alarms and carbon monoxide detector were tested and operational. Outdoor emergency exit clear from obstruction. Signal system and alarms throughout facility were functional.

LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable foods. During inspection, facility was in process of replacing new refrigerator. While food was being taken out of previous refrigerator, LPA observed various frozen meats and foods to not have expiration dates noted . In addition, LPA observed multiple canned items to be expired (Technical Violation given).

LPA observed medication including chest congestion medicine and Delsym to not be properly stored and accessible to residents on top of kitchen counter sink. Opened box of expired medications observed to be in garage not centrally stored or locked (Deficiency cited, see 809D).