Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with staff, Rosa Ascencio. Licensee, Leah Archer came to the facility and gave permission for caregiver to sign report. Annual fees are current. No residents receiving hospice.

LPA/staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 117.3 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required grab bars. Kitchen cabinet containing cleaning supplies was locked. Medications were centrally stored and locked. Fire extinguisher charged and serviced as of July 2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have auditory alerts that were functional at time of visit. Last disaster drill was conducted on January 2026. Facility has at least two days of perishable and one week of non-perishable foods. However, LPA have a conversation with Licensee about having different fruit options other than strawberries, bananas and oranges. Required postings observed. Emergency supply of non-perishable food and water for at least 72 hours of shelter is available.

At approximately 9:30am, LPA/staff observed ceiling located in the living room needs patchwork. According to staff, the Licensee has a contractor who will come to do the repairs.