Facility Evaluation Report

On 01/03/2025 at 7:30 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Direct Care Staff, Margaret Ross who phoned the Administrator about the purpose of the visit. Administrator, Pamela Brown, arrived shortly after. Administrator certificate is current and expires on 06/09/2026. The facility’s fire clearance was approved for a capacity of six (6) ambulatory only.

There are 5 clients currently living at the facility. One client is in a skilled nursing facility.

LPAs toured the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 bedrooms and 2 bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing and bathing are safe, sanitary and in operating condition. There is sufficient supply of hygiene products available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/11/2024. Emergency Disaster Drill was last posted on 10/14/2024. First aid kit was observed to be complete. Fire drill was last conducted on 10/14/2024.

At 7:54 AM, 6 of clients records were reviewed. At 08:30 AM, 3 staff records were reviewed and 3 of 3 have current first aid training and are associated to the facility. LPAs reviewed client's P&I money with log and there was no discrepancies observed. LPAs reviewed clients' medications.