Facility Evaluation Report

07/29/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 5 residents in care. Facility approved/cleared for 6 ambulatory, of which 6 may be non-ambulatory and a hospice waiver for 3. LPA met with Evelyn Serrano, Licensee and Jully Cartel, Administrator. Both Licensee and Administrator gave permission for Caregiver to sign report.

LPA and caregiver toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 126.8 and 123.0 falling out of regulation range of 105 to 120 degrees F (Deficiency Cited). Fire extinguishers were charged and last purchased 09/05/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to residents were located under the kitchen sink and found to be secured. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of 5 resident records. All records had the required documentation. However, LPA observed 2 of the 5 residents to not have an updated medical assessment (Technical Violation). LPA spoke with caregiver about ensuring residents receive an annual visit with a medical professional once every 12 months.