Facility Evaluation Report

Licensing Program Analyst (LPA) David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA D. Roman was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator, Yocsabel Leon. According to the facility’s license, the facility has a maximum capacity of six clients, of whom all are ambulatory.

LPA D. Roman and Administrator, Yocsabel Leon, toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Water temperature was measured at 124 degrees F, however, faucets had identifying labels cautioning hot water. LPA measured shower water temperature in second bathroom at 124 degrees. Administrator reported to have the water boiler reviewed in order to have the temperature lowered.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. Knives were locked in a drawer. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in a locked closet area. No pools or bodies of water on the premises. Per Yocsabel Leon, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors were tested at 2:15PM, emergency lighting, and facility telephone were all working. Fire extinguisher were serviced in March of 2025. First aid kits were complete and readily accessible.

Resident records reviewed however were lacking required documentation, Resident 1 (R1) did not have a physician report but Administrator, Yocsabel Leon, stated she will be provided the information on Friday 05/23/25, once the resident's TB results are provided. Staff records reviewed did not contain first aid and/or CPR certificates. (S1 &S2)