Facility Evaluation Report

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with facility Administrator, Carmen Almero, and explained the purpose for the visit. The facility is a two-story building, operating as an Adult Residential Facility, licensed to serve (14) ambulatory adults, ages 18-59, of which (2) may be non-ambulatory.

During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (5) client medications, (5) client files, (3) staff files, and conducted interviews with (3) staff and attempted to interviews with (3) clients. Five (5) random resident bedrooms were inspected and had the required furniture, storage space, and lighting. There were (2) full bathrooms and (1) half-bathroom. Full bathrooms had the required grab bars and non-skid mats. The water was tested and measured at 109*F, which is in compliance. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables, as well as emergency food and water supplies available. Fire extinguishers were observed throughout the premises, with current inspections and fully charged. Walkways and ramps were observed to be free of debris and obstructions/hazards. Sharps were observed stored in the kitchen, inaccessible to clients in care. Toxins and cleaning supplies were observed stored in the storage room downstairs and underneath the kitchen sink, locked and inaccessible to clients in care. Centrally stored medications were also observed stored in a cabinet, inaccessible. Laundry equipment was observed in good repair and operational during the visit. Sufficient linens, towels, and personal hygiene supplies were available. The facility has an approved mitigation plan on file and a current infection control plan submitted to the department. Sufficient PPE supplies were observed. Smoke/carbon monoxide detectors were observed in each room. Last fire drill was 10/15/23. Staff and resident files were reviewed for required documentation. LPA observed that files for Staff#2 & #3 were missing proof of required annual training. Per the Administrator, training has been conducted but she does not have proof/records of the training completed. The Administrator's Certificate is current with expiration date of: 02/25/2025. Resident's medications were reviewed and observed to be documented properly and given as prescribed.

During today's visit, deficiencies were observed and cited on the LIC809-D page.

An exit interview conducted with Administrator. A copy of the report was provided.