Facility Evaluation Report

On 11/18/2024 Licensing Program Analyst (LPA) Lorena Casillas met with administrator Sarah Long for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:00 am and was greeted by staff member. Three (3) clients were present, and one (1) client was attending program. Staff member contacted Administrator, and Administrator arrived shortly after. LPA informed Administrator of the purpose of the visit. Entrance interview conducted.

A tour of the physical plant was conducted with Administrator at 11:00 am. The facility has four (4) bedrooms and three (3) bathrooms currently occupying four (4) clients. The facility is Fire Cleared for four (4) ambulatory, two (2) of which may be non-ambulatory. Room #3 and #4 are for non-ambulatory clients.

Infection control: LPA reviewed facility mitigation plan (approved on 12/13/21) to make sure licensee was following current infection control recommendations.

Kitchen: LPA conducted tour at the kitchen around 11:20 am observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects, medications, and chemicals being locked and inaccessible to clients in care.

Common Areas: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 69°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:30 am. There are two (2) fire extinguishers located in the kitchen and the laundry room. The fire extinguishers were observed to be full and last serviced on 02/06/2024. Staff and client files were observed to be locked and inaccessible to clients in care.