Facility Evaluation Report

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Vanessa Daniels (Administrator) and explained the reason for the visit. The facility is licensed to serve 1 ambulatory and 3 non-ambulatory only clients ages 18-59. The facility is operating within the scope of its license.

A tour of the single-story facility included the 4 client bedrooms, 2 bathrooms, kitchen, dining area, living room, laundry area, front yard, backyard, and attached garage.

LPA Mora conducted the tour with Vanessa and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps are kept locked under the kitchen sink. Cleaning chemicals are kept locked in a hallway closet. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Medications are kept locked in a hallway cabinet. Client and staff files are kept in the garage. Clean towels and extra clean linen were observed in a hallway cabinet. Dining and living room have sufficient lighting and sitting area. All bedrooms have all required furniture, lighting, and bedding. The bathrooms were observed with shower mats and grab bars for non-ambulatory clients. The water temperature was tested in the both bathrooms and measured at 116 degrees F and 116.3 degrees F, which is within the required 105-120 degrees F. Fire extinguisher were observed in the laundry area and hallway, and are fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. The carbon monoxide was observed in the living room and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction. Medications for all 4 clients was reviewed. Medications are documented properly and given as prescribed. Files for all 4 clients and 5 staff were reviewed. No deficiencies found with the files.