Facility Evaluation Report

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Henry Lara Assistant Administrator and explained the reason for the visit. The purpose of the visit is to complete the required inspection. Shortly thereafter Kathleen Travieso Administrator arrived.

LPA Trueman toured the facility along with Henry Lara Assistant Administrator today 05/01/2025 at 10:00 AM and the following was observed:

Facility contains 3 Client Bedrooms and 1 Client Bathroom, dining room, living room, TV room, and outdoor backyard area.

Annual Inspection includes the following Domains:

Infection Control, Physical Plant and Environment 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.

Interview was conducted with 1 staff. The 4 clients were at their Day Program. 7 Staff files were reviewed and 2 client files were reviewed

Medication was administered per physician's directions.

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

Licensee kept on file client medical assessment.

Licensee maintained an individual admission agreement for each client.

Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations.

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.