Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Aiona Grace Gazil, Direct Service Professional (DSP) and explained the purpose of the visit. Administrator Marilyn Sabio has been contacted by phone several times to no avail. The Administrator arrived at 2:26pm to assist LPA. The facility is licensed to care for Mentally Disabled Adults, ages 18 through 59, ambulatory only. Six (6) clients in 15027 only and six (6) clients in house 15031. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has no plan of operation or infection control plan in place. DSP Aiona stated that she will submit the current plan. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located near the front door. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements: Proof of Surety Bond was unavailable at the facility and Administrator will submit a copy to CCL/LPA. Last Fire Drill was conducted on 5/11/2022.

Physical Plant/Environment Safety: The facility contains 2 Houses, House #1 is a structure located in the back (15027) consists of (4) clients bedrooms, (2) full bathrooms, kitchen area which is also utilized as a staff room, living room and a backyard. House #2 located in front (15031) consists of (3) bedrooms, (1) of which is being used as a staff room, 2 full bathrooms, living room, dining area, kitchen, laundry area, office area front porch, patio and detached garage. Currently, there are ten (10) clients living in the facility and all were out in the day program during the visit. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, and sufficient closet space. However the clients bedrooms were not equipped with night tables and reading lamps. Most of the bedrooms did not have trash cans. Bathrooms contained hygiene supplies including liquid soap, paper towels, and toilet paper, but did not have non-skid materials in the shower area . LPA observed that there are no window screens in some of the windows in both s tructures. LPA also observed cracked glass window in front of House #1 and was broken. Additionally, window sill/moldings are broken and chipped in bathroom #2 in House #2. Exit doors are free of obstruction and there are no pools or large bodies of water. Backyard was inspected and observed to be obstructed. LPA observed unused items like grocery carts filled with trash, used cans and bins outside house #2. Detached garage was inspected and LPA observed that the garage is in disarray. Chemicals and other hazardous materials were stored along with other furniture, beddings and food items. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There are three (3) fire extinguishers observed to be expired and were last serviced on 2/28/2020. Smoke alarms and carbon monoxide were tested. (2) Smoke detectors in house #1 are broken and inoperable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. At 11:30am, hot water supply measured at 116.2 deg F in the kitchen sink, in House #1: 118.2 deg F in bathroom #1, 113.5 in bathroom #2, House #2: 117.4 deg F in bathroom #1 and 113.9 in bathroom #2.