Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced annual inspection at the facility today and met with Administrator Ivy Sudjati. Entrance interview conducted.

At 10:45 a.m. the LPA conducted a tour of the physical plant with the Administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted:

The facility is a single-story home, which consists of 5 (five) bedrooms and 4 (four) bathrooms. There is no staff room and staff will remain awake at night.. The LPA observed one (1) fire extinguisher which was fully charged and last serviced on 03/27/2025. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed the required postings in the entry way and common sitting area.

KITCHEN/FOOD SERVICE AREA: The facility has a sufficient supply of non-perishable foods, emergency food and water. Knives and sharp items are stored in a locked box. Cleaning supplies and disinfectants are stored underneath the locked kitchen sink and in the locked garage. The facility has a sufficient supply of plates, cups and utensils.

RESIDENT BEDROOMS: All resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding.

Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. The hot water temperature in resident restrooms measured at 117 degrees Fahrenheit. Report will continue on LIC809-C.