Facility Evaluation Report

Licensing Program Analyst (LPA), Yelena Avetisyan, conducted an unannounced Required 1 year inspection at the facility. LPA was greeted by staff, Ronell Ocampo, who granted access to the facility. administrator Mary Jane C. Montiano arrived to the facility approximately 4:00 pm.

Approximately 2:15 pm LPA conducted a tour of the facility with the assistance of the staff

Infection control: Upon arrival, LPA was screened, however not asked to sign-in the visitors’ log. In addition, LPA was not asked all infection control questions. Proper signage was observed inside the hallway and in the restrooms. Hand sanitizer was also observed. LPA advised the administrator to review their mitigation plan with all staff to ensure all visitors are thoroughly screened upon entry. LPA observed all trash can throughout the facility have fitted lids.

Kitchen: LPA toured the kitchen area and observed sufficient supplies of non-perishable food for a minimum of 1 week and perishable food for 2 days at the facility. All knives and sharp objects were observed in a locked drawer and inaccessible to clients in care. The fire extinguisher is located in the kitchen and was observed to be fully charged.

Smoke detectors/carbon monoxide . Smoke detectors are hard wired and battery operated and were located throughout the facility. At 3:25pm the smoke detectors were tested and observed to be operational. At 3:24 pm staff tested the carbon monoxide detector which was not operational. At 3:30 pm Staff changed the batter and retested the carbon monoxide detector which was operational.

Bedrooms: There are three (3) bedrooms designated for clients' use and have sufficient lighting. All bedrooms were not properly furnished. All rooms had a strong odor, While touring the residents rooms LPA observed the following: Broken blinds, closet doors cracked, flooring cracked, window panels, mirrors and furnishings dirty/dusty.