Facility Evaluation Report

On 12/04/2023 at 2:55 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Sister Mary Ann Leyba and explained the purpose of the visit. The facility’s fire clearance was approved for 3 Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which all 3 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature for clients is maintained at 68 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured within range of 105-120 degree Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/05/2023.

At 3:55 PM, LPA reviewed 3 of 3 client records and medications. At 3:35 PM, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.

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