Facility Evaluation Report

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, co-licensee, Nena Casuga.

This facility is licensed for a total of 6 in which 4 of the residents may be non-ambulatory. There is currently no residents living in the home and there was no one available, Nena Casuga and Aileen Bryant arrived a few minutes later.

LPA toured facility and grounds and observed facility was found to be clean at a comfortable temperature, with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods. Fire Extinguisher was found to be charged, and serviced 3/24/2024. Smoke alarms and Carbon monoxide detector are operational. Medication will be centrally stored and locked in the kitchen pantry.

Hot water temperature read 107.1 and is within the required range of 105- 120 degrees f.

Licensee/Administrator to submit the current following documents by 6/1/2024:

· LIC 308 Designation of Facility Responsibility

· LIC 400 Affidavit Regarding Client/Resident Cash Resources

· LIC 9020 Register of Facility Residents

Infection Control Plan of Operation (If changes)