Facility Evaluation Report

Licensing Program Analyst (LPA) J. Duarte arrived at the facility unannounced to conduct an Annual Inspection. LPA was greeted and granted entry by staff. Saff contacted Administrator Ulysis Baal and he arrived shortly after. Staff reported that the facility has four residents and all residents were present.

The facility was observed to be at a temperature of 73 degrees F, clean with no passageway obstructions. The living room has sufficient seating for residents. The kitchen was toured and LPA observed a two-day supply of perishable and seven-day supply of non-perishable food. The facility stores sharps in a locked kitchen cabinet. Medication is kept secured in a locked kitchen cabinet. A fire extinguisher was observed in the kitchen, with a service date of 06/05/2025. A complete first Aid Kit was observed secured to the wall next to the kitchen.

All bedrooms were toured and observed to have the required furniture and adequate lighting. Restrooms were equipped with grab bars in the shower and next to the toilet, non-slip mats were observed in the showers. The hot water temperature in the restrooms was tested and measured between 107 and 110 degrees F.

The facility has a dryer and washer in the garage. Chemicals and detergent were observed locked in cabinet. Outside of the facility was toured and observed to be free of debris. The facility has a back patio with seating available. LPA observed the facility sketch reflects Gate #2, that exits towards Sutton Place, has been removed and there is only a fence with no gate. The exterior has an additional exit, Gate #1, that exits towards Scarborough Lane. Gate #1 remains in place and functioning.