Facility Evaluation Report

Licensing Program Analyst ( LPA) Alberto Lopez made an unannounced annual inspection visit. LPA met with DSP Teresita Sapanghila and Administrator Gemma Rodriguez arrived a few minutes later and assisted with the visit. LPA explained the purpose of today's visit.

This is a one story adult residential facility (ARF) facility consisting of 3 client bedrooms 2.5 bathrooms, kitchen, dining room, activities room, laundry room, storage room, medication room and outdoor shaded activity area. This facility is licensed at a capacity of 6 clients and today's census was 6

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 still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance.

Physical Plant & Environment Safety: LPA observed 3 client bedrooms/bathrooms and closet/drawer space to accommodate each client comfortably was available. The facility is free of debris/hazards and the outdoor passageways and activity area are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 106.1 – 107.4 degrees F which is within required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in accessible to clients. The last Fire/Emergency Drill was conducted on 04/18/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and recently inspected.

Operational Requirements: Facility is in compliance.

Staffing : There appears to be always sufficient staffing in the facility. Administrator Gemma Rodriguez certificate expires on 03/16/2024.

Personnel Records-Training : Staff has criminal record clearance. Staff has current first aid and CPR. Staff files are maintained at the facility located in a locked cabinet in the living room. Staff have current CPR/first aid training and sufficient on-going training.