Facility Evaluation Report

On 01/29/25 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (ADM, DSP) and explained the purpose of the visit. ADM has a current administrator certificate# 7003760735 which expires 03/02/26.

At 1PM, 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. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Fire extinguisher was observed fully charged and last inspected on 02/05/24.

Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. 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 4 staff and 5 client files.

No deficiencies observed during visit. Exit interview conducted and a copy provided.