Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management-Annual Continuation visit for the required 1-year inspection. The initial visit was conducted on 12/20/2024, no deficiencies cited at the time. LPA met with Jose Hernandez, Cook and explained the purpose of the visit. Administrator, Estefany Lopez arrived shortly after and assisted LPA with the inspection. LPA continued to utilize the Compliance and Regulatory Enforcement (CARE) tools and observed the following:

Physical Plant & Environment Safety: The facility consists of (5) buildings, the main building and (4) single story cottages (E1-E4). There are two levels in the main building and has (7) bedrooms in the lower level, (21) bedrooms in the upper level, bathrooms for men & women, dining room, kitchen, living room with a fireplace, office/medication room and a laundry room. E1 consists of (6) bedrooms and (2) bathrooms, E2 consists of (4) bedrooms and (2) bathrooms, E3 consists of (4) bedrooms and (1) bathroom and E4 consists of (3) bedrooms and (1) bathroom. Random client bedrooms were toured in the main building and the (4) cottages. The bedrooms in the main building has fire sprinklers, smoke detector, bed, linen, dresser, light, chair and sufficient closet space. The bedrooms in the (4) cottages have smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. At 10am, LPA measured the hot water supply in several bathrooms and read between 106 deg F to 109.2 deg F which were within the required 105 - 120 degrees Fahrenheit. There are (2) laundry areas in the facility with sufficient amount of washers and dryers. At 10:10am, LPA observed that the door in the laundry room where they store disinfectants, laundry soaps and other cleaning solutions was left unlocked and ajar. LP A observed that the fireplace in the living room was not properly screened and covered. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. LPA observed that one of the freezers in the kitchen was dirty and has rust on the bottom shelf. LPA also observed that the trash cans/bins in the kitchen and bathrooms did not have covers. There are no firearms or weapons stored at the facility. Exit doors are free of any obstruction and there are no pools or large bodies of water. Facility provides a shaded area and sitting area for the clients. The facility has a video camera monitor system in all common areas and hallways. The facility has a total of 2 elevators, one in each building and were operational. Fire alarms, carbon monoxide detectors and the signalling systems are interconnected and notify the fire department when triggered. Toxins and sharps locked and inaccessible to residents. Fire extinguishers were observed to be fully charged and inspected on 10/11/2024.