Facility Evaluation Report

On 12/28/23 at 10:40AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit.

At 12PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas.

At 12:30PM, LPA observed facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Medications were observed locked in cabinets. Toxic chemicals were stored and locked in storage shed.

Comfortable temperature is maintained at 68 deg F. Hot water temperature was measured at 117 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. P&I monies were observed separate from facility funds and matched record logs. LPA reviewed 3 staff and 5 client files. LPA also conducted 2 staff and 2 client interviews during visit.