Facility Evaluation Report

At 10:00 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a pre-licensing visit to the above noted facility. The LPA met with applicants, Cleofe S Barretto and Arlene Martinez. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver for three (3) has been requested. Component III was completed during the inspection with the applicants.

The facility is a single story home. At 12:05 PM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing the home for five (5) non-ambulatory residents in rooms #2, 3, and 4 and one (1) bedridden resident in room #1. The facility has two (2) private bedrooms and two (2) shared bedrooms. Bedroom #1 and #4 have direct access outside. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with comfortable mattress and clean linen; which includes, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. The facility does not have a staff room, therefore will have 24 hour awake staff. All rooms were free of odors. All window screens were clean and maintained in good repair.

There is one (1) common restroom in the hallway and one private restroom in bedroom #4 . Both resident bathrooms have showers with grab bars and non-skid materials. The hot water temperature was measured as follows: resident’s private bathroom in room #4 = 111.7 *F, and resident's common bathroom 111.9*F and the kitchen – 110.7 *F, which fall within the allowable range of 105*F to 120*F.

Report continued on LIC 809-C (2ND PAGE).