Facility Evaluation Report

On 4/20/2023 starting at 11:00 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Care Staff- Victoria Francisco and explained the purpose of the visit. The facility’s fire clearance was approved for all six (6) ambulatory clients. Upon entry, LPA observed two (2) staff and four (4) clients present during inspection.

Starting at 11:20 AM, LPA toured facility with care staff including but not limited to four (4) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 2 bedrooms are private, and 2 bedrooms are shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in clients’ common area bathroom was measured at 108.4 Degrees Fahrenheit. Clients’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Sharps and toxins were locked and inaccessible to clients'.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 3/2/2023. First aid kit was observed to be complete.

Starting At 12:00 PM, LPA reviewed 2 of 2 staff records. At 12:10 PM, LPA reviewed 4 of 4 clients' records. At 1:27 PM, LPA reviewed a sample of 3 of 4 clients' medications.