Facility Evaluation Report

At 10:30 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a pre-licensing visit to the above noted facility. The LPA met with applicant representative, Roberto Ramirez. This is a a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver for six (6) has been requested. Component III was completed during the inspection with the applicant.

The facility is a single story home. At 12:00 PM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing the home for six (6) non-ambulatory residents in rooms #1-4. The facility has two (2) private bedrooms and two (2) shared bedrooms. Bedroom #2, #3 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. All rooms were free of odors. All window screens were clean and maintained in good repair.

The LPA observed a makeshift staff room in the passageway leading to the garage. Upon observation, the beds and other items in the makeshift staff room were removed. Applicant representative understands that the facility does not have a staff room, therefore will have 24 hour awake staff and cannot have staff sleep in the facility including the garage unless there is an approved staff room.

There is two (2) common restrooms . Both resident bathrooms have showers with grab bars and non-skid materials. The hot water temperature was measured as follows: resident's common bathroom outside of room #4 117.9*F, common restroom outside of rooms #1 and #2 117.1*F which fall within the allowable range of 105*F to 120*F.

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