Facility Evaluation Report

Licensing Program Analyst (LPA) Alberto Lopez conducted the annual inspection. LPA arrived unannounced and Staff Elizabeth Del Mundo allowed entry. Administrator, Terry Del Mundo, arrived shortly after to assist with the visit. The facility is licensed to serve a total of 6 adults, of which 1 may be non-ambulatory and 5 bedridden.

LPA toured the facility and observed the following:

There are 5 Client bedrooms, 3 bathrooms, living room, dining room, and kitchen. The laundry area is located inside the 3rd bathroom with 2 showers.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.

Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was not within the required range. It measured 136.2 – 138.0 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and is fully charged.