Facility Evaluation Report

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Vanessa Daniels and explained the reason for the visit. Physical Plant was toured, client files and medication records were reviewed, staff files reviewed and food supply was inspected.

LPA and Administrator toured the home and inspected 4 client bedrooms, 2 bathrooms, kitchen, dining area, living room, laundry area, front yard, backyard, and attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in both bathrooms and both measured at 117 degrees F which is within the required 105 - 120 degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in good condition. There is a cabinet in the hallway with extra clean linen and towels. Smoke detectors were observed in each room, the hallway and living room. There is a carbon monoxide in the living room. There are 3 fire extinguishers located in the kitchen, hallway, and garage which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked under the kitchen sink and are inaccessible to clients. Cleaning supplies and toxins are locked under the kitchen sink and are inaccessible to clients. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet in the hallway. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed in the kitchen. Medications are centrally stored in a locked cabinet in the hallway. Client files are kept locked in the staff closet near the entrance. Staff files are kept locked in a file cabinet in the garage. All four of the client files and medications were reviewed and no deficiencies were found. Medications are documented properly and given as prescribed. Five staff files were reviewed and no deficiencies were found.