Facility Evaluation Report

On 10/14/2023 at 8:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Staff Members Dara Stanton and Kingsley Nwala. Administrator (ADM) Carrie Aquino arrived at approximately 9:30 AM.

The LPA toured the interior and exterior of the 3 buildings on the facility grounds, including but not limited to client bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor areas. The LPA observed adequate lighting in all of the rooms for the comfort and safety of the clients. LPA observed 7 days of nonperishable and 2 days of perishable foods on hand. Sharps and dangerous items were inaccessible to clients. Client rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction. There were no bodies of water observed.

Smoke detectors and carbon monoxide detectors were fully functional. Fire extinguishers were observed to be full and last serviced on 8/20/2024. Temperature in the facility was measured at 72.1 degrees Fahrenheit at 10:34 AM and the hot water measured at 108.5 degrees Fahrenheit at 10:31 AM.

The LPA reviewed the records of 5 clients and 5 staff members. The LPA interviewed 3 staff members. Because clients were on an off-site outing when LPA attempted to conduct interviews, no clients were interviewed.

Exit interview conducted and a copy of this report provided.