Facility Evaluation Report

03/26/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. There are currently four residents in care. Upon arrival LPA was notified all residents were gone attending day program. Facility is approved for two ambulatory and four non-ambulatory.

LPA conducted a review of four resident records. All records had the required documentation. LPA reviewed resident cash resources. LPA conducted review of three staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

LPA and Administrator 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 furnished per regulation. All rooms were in good repair. Extra hygiene products and linens were available. LPA was unable to measure water temperature during the inspection as facility had the water shut off due to a leak upstairs in bathroom #2 and was being repaired, however facility has a waterless tank and LPA was able to see the water temperature was set at 115 degrees F. Fire extinguishers were last inspected December 2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Sharps were located in a kitchen drawer and were 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. Facilities last fire drill was conducted 02/14/2026.