Facility Evaluation Report

On 05/01/2023 at 11:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by staff member, Dodie Aguilucho and explained the purpose of the visit. LPA asked for SM Aguilucho to contact the Facility Designated Administrator to inform them that CCL was present at this time. It was learned at this time that FDA Antonio was unable to meet the LPA at this time. Shortly after, LPA met with Facility Designated Representative (FDR), Maria Angelica Souxouay.

This facility is licensed to serve 6 residents, who all may be deemed non-ambulatory. This facility also has a dementia plan on file.

LPA reviewed 5 resident files and 2 staff files. All files were current and up to date. Facility Administrator has a current and active administrator certificate #6055145740 and expires on 01/27/2024.

The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Jorgenson Co on 02/28/2023.

The kitchen area was toured. LPA observed a 7 day non-perishable and 2 perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage.

LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.