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 11:50 am and was greeted by Administrator. LPA informed the Administrator of the purpose of the visit, entrance interview conducted.

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

A tour of the physical plant was conducted with the Administrator at 12:00 pm. The facility has three (3) bedrooms and two (2) bathrooms currently occupying four (4) clients. The facility is Fire Cleared for four (4) ambulatory. All clients were out in the community.

Kitchen: LPA conducted a tour of the kitchen at 12:10 pm and 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 object locked under the kitchen sink and observed the medication cabinet locked and inaccessible to clients in care. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 10/01/2024.