Facility Evaluation Report

On 03/15/2024 at 9:45 AM, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived unannounced to conduct an Annual 1-year required inspection. LPAs met with Rosa Ramos, Supervisor, and explained the reason for the visit. The facility's fire clearance was approved for 8 ambulatory.

LPAs inspected the facility with Supervisor, which included but not limited to the bathrooms, kitchen, back yard, and common areas of the facility. LPAs observed the facility to be free of odor, clean and in good repair. There is a comfortable room temperature of 73 degrees Fahrenheit for clients in care. Clients bring their own lunches and snacks to facility. The hot water temperature in the shared bathroom measured 118.3 degrees. All observed toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed. Carbon monoxide and smoke detectors found to be in working order. Toxins and sharp objects were locked and inaccessible to clients. Emergency disaster plan last updated 07/24/2023. Fire extinguisher last services 11/01/2022. Fire drill last conducted 08/10/2023. First aid kit was checked and is complete.

LPAs reviewed two (2) staff files and two (2) staff files weren't available for review. LPAs reviewed six (6) clients and all were missing Appraisal Needs and Service Plan.