Facility Evaluation Report

On 09/05/24 at 12:10PM, 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. LPA observed ADM has current administrator certificate# 6050391735 which expires 12/16/2024.

At 12:25PM, 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 sanitizer were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper handwashing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 75 deg F. Hot water temperature was measured at 107 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. Two fire extinguishers were observed fully charged and last inspected on 08/01/24. LPA reviewed 5 staff and 5 client files. P&I monies were observed matching recorded logs and separate from facility funds.

Updated copies of the following documents were obtained from administrator:

 LIC308- Designation of Facility Responsibility

 LIC610D- Emergency/Disaster Plan including infection control plans

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