Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:35AM. LPA initially met with facility staff. Licensee Cilva Toume was contacted over the telephone and arrived at 12:37PM. Entrance interview conducted.

Beginning at 12:48PM, the LPA, along with Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed :

Fire extinguisher is fully charged an d purchased on 05/23/2024 . Smoke detectors were tested at 02:39PM, Carbon Monoxide detector was tested at 02:40PM. A l l were functional at the time of the visit.

BEDROOMS : There are 8 (eight) total bedrooms in the facility; 6 (six) bedrooms are designated for resident use, 1 (one) staff room and 1 (one) room is utilized for storage. The staff room is kept locked and the storage room did not contain any hazardous items. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. LPA observed full bedrails on 2 (two) residents' beds, however these residents (Resident #1 - R1 and Resident #2 - R2) are not on hospice and do not have valid exceptions on file with the Department.

BATHROOMS : There are 3 (three) total bathrooms in the facility. 1 (one) is used for staff, 1 (one) is a private resident bathroom, and 1 (one) is a hallway bathroom designated for shared resident use. Resident restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in shared resident bathroom and measured in compliance with regulation.

COMMON AREAS : This includes the living room and dining room areas. LPA observed common area to be