Facility Evaluation Report

Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Adela Santos and discussed the purpose of today’s visit.

This facility consists of four (4) single-story buildings which accommodates (12) double-occupancy rooms each. There is also a building which consists of the medication room, offices, activities room, main storage room and laundry room and a kitchen with dining area.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has an Infection Control Plan in place.

Physical Plant & Environment Safety: Smoke/Carbon Monoxide observed. Fire extinguishers are located throughout the facility with a last service date 03/05/24. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients.

Operational Requirements: The fire clearance is approved for (78) ambulatory and (6) non-ambulatory clients. Staff are adhering to operational requirements.

Staffing : There is sufficient staffing at the facility. Administrator Certificate for Adela Santos expires on 07/14/24. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training : Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 (S-1) through Staff # (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

**Refer to LIC 809C for the continuation of this report**