Facility Evaluation Report

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to complete the annual inspection. The initial inspection was conducted on 06/22/2023. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and completed the remaining domains:

Physical Plant & Environment Safety: Smoke alarms and signal system were tested and operable. Fire extinguishers are located throughout the facility (each hallway of every unit) with a last service date 03/15/23. Carbon monoxide detectors are located throughout the facility (each hallway of every unit/tested and operable). Hot water supply measured within 106.5* to 112.0*. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Additional food supply is stored inside the storage room near the medication room. Per Administrator, there are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored inside the medication room. LPA reviewed medication for C-1 through C-6. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610/9 pages) in place.

Emergency Intervention: Per Administrator, staff do not use manual restraints nor seclude clients.

Exit interview, appeals rights and a copy of this report was provided to Adela Santos. Note: LPA was experiencing technical problems during this visit.