Facility Evaluation Report

On 1/6/2023, Licensing Program Analyst (LPA) James Sampair conducted an unannounced post licensing inspection. LPA explained the purpose of the visit to Administrator (ADM) Ophelia Pedroso upon entry . LPA and ADM inspected the facility inside and out.

The facility has an infection mitigation plan in place, and the Infection Preventionist is Ophelia Pedroso . However, the staff are not following the latest COVID-19 infection control guidance, including masking. Though they have one central entry point at the front entrance, their visitor's log did have a space for recording visitor's temperature.

There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency water supply was observed but not food supplies. Hot water and facility room temperatures maintained at comfortable temperatures. However, a bathroom sink was completely inoperable. Fire extinguisher fully charged and serviced within the past year and carbon monoxide and smoke detectors operational. Administrator is on site a minimum of 20 hours a week to oversee proper business operation.