Facility Evaluation Report

Licensing Program Analyst(LPA) Alviso conducted a required- 1 year inspection, on 2/3/26 at approximately 3:00pm, and met with Rafael Mendoza, Administrator, and Tamra Richmond, Business Office Manager.

The facility has a required infection control plan. Hospice waiver is approved for ten (10) residents only. The facility has a required emergency and disaster plan. Facility is fire cleared for seventy-five (75) non-ambulatory residents.Fire cleared resident rooms/units are 157-187 on the first floor, and 257-287 on the second floor. Fire extinguishers were serviced and tagged.

The LPA toured the facility with the Administrator, and the Business Office Manager. The facility had sufficient lighting in units/offices observed by the LPA. Sufficient lighting in common areas, restrooms, hallways, and dining room, The kitchen was found to be orderly and clean during the inspection; The freezer and refrigerator were clean and observed to be within required temperatures. Sufficient food supply was observed. All exits were free and clear of obstruction. Medication room was relocated to the 2nd floor; The medication room was locked as required, making medications/over the counter medications inaccessible to residents in care. Housekeeping carts, cleaners/disinfectants were locked, and inaccessible to residents in care. Hot water was measured at 115.7 degrees Fahrenheit. Facility had sufficient furnishings for resident use. Large common area with a library for use by residents. LPA observed the residents in the dining room for the dinner meal being served, and for meal pick-up orders.

The LPA will complete the annual inspection at a later date.