Facility Evaluation Report

On 1/19/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival, LPA called the facility to conduct a risk assessment with House Manager Leticia Pacheco. Based on the assessment, the facility is clear of Covid-19 infection. LPA met with House Manager Leticia Pacheco and explained the purpose of the visit. Case Manager Philip Guaglianone and Administrator Carol Liess arrived later and joined the visit.

The facility is approved to serve (nine) 9 ambulatory adults with a mental health diagnosis. Currently, the census for client is nine (9) and staff census is three (3). LPA verified that the facility has an approved mitigation plan report.

LPA and House Manager Pacheco toured the inside and outside grounds of the facility. There were no bodies of water or obstructions on the premises. All rooms were inspected and had adequate lighting and furnishings. A comfortable temperature was maintained in the facility. There are three (3) fire extinguishers last serviced on 1/25/2022. The last fire drill was conducted on 12/30/2022. Smoke alarm system was tested and found to be operable. The water temperature was measured at 115.9 degree Fahrenheit. Medications are locked & centrally stored in a locked room. The first aid kit has all required supplies.

During the visit, LPA observed the following to be in compliance: the facility's infection control practices; screening protocols for visitors, staff, and clients, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA requested a copy of facility's liability insurance. LPA observed several other facilities are listed on the certificate. LPA will verify is the insurance coverage is sufficient.