Facility Evaluation Report

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Karina Andrade and explained the reason for the visit.

The purpose of the visit is to complete the required inspection.

LPA Trueman toured the facility along with Administrator Karina Andrade today 02/01/2024 at 9:45 AM and the following was observed:

Facility contains : Activity room, computer room, 2 restrooms, and resting room. Food is served for lunch from an outdoor vendor. Medications are currently not being administered for the clients currently attending program.

Annual Inspection includes the following Domains:

Infection Control, Physical Plant and Environmental Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client rights- Incident Reports, Food Service, Health Related services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention.

Ratio is 1 staff for every 4 clients. The census is 14 with 5 staff on shift.

Interviews were conducted with 5 clients and 4 staff. 5 client files and 5 staff files were reviewed

Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.

Direct care staff had a minimum of 8 hours of annual training,

Licensee maintained an individual admission agreement for each client.

There is an adequate number of direct care staff to support each resident's physical, social, emotional safety and health care needs as identified in his/her current appraisal.

Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.

Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.

No deficiencies. Exit interview conducted.