Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Erica Campos, Lead Staff and Aida Reznik, Licensee arrived later. There are three residents receiving hospice services. Annual fees are current. Required postings observed.

LPA/staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature, well lit and passageways were free from obstructions. Resident rooms were furnished per regulation. There are portable heaters observed in resident's rooms. Per staff, the room is shared by two residents who have different preferences regarding the temperature of the room (technical violation issued). Water temperature in bathrooms used by residents measured at 108.1, 114.8 and 115.3 degrees F which are all within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. However, bathroom's and resident's garbage cans do not have well-fitted covers to prevent the spread of any communicable disease. Last year, LPA discussed with the Licensee the importance of having garbage cans with covers and technical violation was issued. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked in the medication room. Four out of six fire extinguishers were last inspected January 2025. According to lead staff, it appears like the remaining two fire extinguishers were missed when the vendor came to service the other extinguishers. Facility has a centralized smoke alarm and sprinkler system that is maintained by a vendor. The most recent inspection was conducted November 2025. Carbon monoxide detectors were tested and operational. Exit doors have auditory alerts that were functional at time of visit. Each resident has a pendant to alert staff if the resident needs assistance. Last Disaster Drill was conducted on September 12, 2025.