Facility Evaluation Report

On 12/04/2024 at 9:00 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1 year required annual. LPA met with Administrator, Maria Fatima Lacsamana and explained the purpose of the visit.

LPA toured the client’s bedrooms, bathrooms, common living areas, kitchen, garage and backyard. There are four (4) bedrooms, and three (3) bathrooms. There is sufficient lighting around the facility. Clients' rooms are equipped with the proper furniture, bedding and lighting. Hot water temperature is measured at 113.8 degrees Fahrenheit. LPA observed locked cabinets that store toxins and sharps and a locked mobile cart for medications. Required posters are posted on the wall. Thermometer in hallway showed temperature as 71 degrees F. Emergency disaster plan dated 01/01/2024. Fire drill last conducted 08/27/2024. Fire extinguisher was last serviced on 10/28/2024. First Aid kit was complete. Carbon monoxide/smoke detectors were in working condition. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. Fire extinguisher was observed serviced. LPA observed facility passages inside and out free of obstruction.

LPA reviewed 4 clients files and 2 staff record. 2 out of 2 staff record have TB and current CPR/First Aid on files.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.