Facility Evaluation Report

Licensing Program Analyst (LPA) Lorena Casillas met with Administrator James Durando for an unannounced one (1) year Required visit for this facility.

LPA arrived at 9:30 am and was greeted by caregiver and Administrator. One (1) resident observed in the living room watching TV, one (1) resident in the community, and two (2) residents at day program. LPA informed the Administrator of the purpose of the visit. Entrance Interview conducted.

A tour of the physical plant was conducted with the Administrator at 09:50 am. The facility has seven (7) bedrooms and three (3) bathrooms. Four (4) rooms are currently used by residents, one (1) bedroom is used as an office, one (1) room as a storage room, and one (1) room is used as a staff bedroom. LPA observed that staff bedroom was locked, and residents do not have access to it.

Infection control: LPA reviewed facility mitigation plan (approved on 04/22/2021) to make sure licensee was following current infection control recommendations.

Living and Dining : The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. No obstructions or tripping hazards throughout the facility. There is a fire extinguisher by the kitchen, and it was last serviced on 12/18/2023. The laundry area was located in a backroom and all chemicals observed to be locked and inaccessible to residents. The washing machine is currently being repaired and a replacement washing machine is being used instead, Administrator states that they are waiting on parts for the broken down washing machine. The replacement washing machine is located in the facility and is functioning properly. Smoke and carbon monoxide detectors were located throughout the facility, and at 10:15 am they were tested and observed to be operational.