Facility Evaluation Report

Licensing Program Analyst (LPA) Lorena Casillas met with administrator Linda Hughes for an unannounced one (1) year Required visit for this facility.

LPA arrived at 9:20 am and was greeted by staff member. Administrator arrived shortly after LPA arrival and was informed of the purpose of the visit. Entrance interview conducted. Staff informed LPA that all clients were currently attending day program.

A tour of the physical plant was conducted with Administrator at 09:30 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. The facility is Fire Cleared for four (4) ambulatory clients.

Infection control: LPA reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations.

Kitchen: LPA conducted tour at the kitchen around 09:40 am observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects, medications, and chemicals being locked and inaccessible to clients in care.

Common Areas: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 71°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 12:30 pm. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 10/04/2023. Staff and client files were observed to be locked and inaccessible to clients in care.