Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct a Required - 1 Year inspection, on 9/30/2025 at approximately 10am, and met with Sandra Ambrecht, Administrator.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. The facility has a required infection control plan. The facility has a required emergency disaster plan. Fire clearance is approved for six (6) non-ambulatory. There are currently four (4) residents in care.

The LPA reviewed four (4) resident files. All files were complete.

The LPA reviewed three(3) staff files. All staff have required criminal record clearance. All staff have current First Aid and CPR as required. All staff have training as required.

LPA toured the facility with the Administrator. All exits were free and clear of obstructions. Fire extinguishers were serviced and tagged as required. All rooms were clean and orderly. Food supply was sufficient in perishable and non-perishable food items. Sufficient supply of disinfectants/cleaners, paper products, personal protective equipment (PPE), linens, and furnishings. Medications were locked up and inaccessible to residents in care. Hot water measured at 116.4 Fahrenheit.

All cleaners/disinfectants were locked and inaccessible to residents in care. LPA observed sufficient lighting in common areas, hallways, bathrooms, and resident rooms. There was seating outside on the facility's porch/deck which is accessible from resident rooms slider doors, and seating in the front area for residents' use.