Facility Evaluation Report

On 10/06/21 Licensing Program Analyst (LPA) Jade Jordan Arrived to conduct an unannounced Annual Inspection, with an emphasis on Infection Control. LPA confirmed by Telephone with Administrator Warren

Trinidad, that there were no Positive Covid -19 Cases within the facility. Upon entry the purpose of the visit

was explained. LPA Observed Required Posting, including hand washing Hygiene, and was screened for temperature, by Staff Danny. LPA was later met by Administrator Mary Grace Trinidad, who assisted in giving a physical plant tour. This facility is licensed to serve (20) Ambulatory, Mentally Disabled Adults ages 18- 59.

The facility has 10 shared client rooms, two unisex client bathrooms, one shared private bathroom in room 8,9, and one designated staff bathroom located near storage. The 3 client bathroom which have 3 toilets, 3 sinks, and 3 showers. The toilets have doors for privacy, and the showers have curtains for privacy. During the tour, LPA Jordan observed client bedrooms, there is one vacancy. Each bed has all required linen, the rooms have sufficient closet & drawer space, there are chairs available in the rooms, and the smoke detectors are functioning properly. Last fire drill conducted in July of 21. LPA toured the outside yard area, and there are no hazardous items in the yard. There is a front porch with chairs where clients may sit and smoke or relax. The washer & dryer are in the laundry room in the hall, and laundry supplies are also kept in the locked laundry room. There is a 7 day supply of non-perishable foods, and a 2 day supply of perishable foods in the kitchen. An additional supply of perishable and non-perishable food in the storage, and in commercial size freezer. Sharp knives are locked in the kitchen. Toxic cleaning agents are locked under the sink in the kitchen.

Medications were observed locked in a cart in the kitchen. LPA reviewed the client medications & the medication log book, client files, and staff files.