Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was met and screened for covid upon entry into this home by Ngozi Williams-Onwuso, Direct Support Professional/DSP. LPA explained the purpose of today's visit. The facility is approved for 4 Developmentally Disabled Adults, ages 18-59 and ambulatory only. There are current 4 ambulatory clients residing at the home. At 10:45a.m., Administrator Linda Williams arrived and assisted LPA with the inspection. This single-story home contains three (3) bedrooms, two (2) bathrooms, a living room, kitchen, dining area, office area, backyard, and detached garage.

The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.

COVID-19 signage was placed in several areas of the facility.

Facility maintained a 30-day supply of PPE located in the supply closet inside the home and garage.

The kitchen was inspected. There were sufficient supplies of 2-day perishables and 7-day non-perishable foods. All the appliances are clean and working properly.

Cleaning solutions and kitchen knives/sharps were locked and stored in the storage/supply room and inaccessible to clients.

Hot water temperature was measured in kitchen and bathrooms. Kitchen read at 113.2 deg F, bathroom #1 read at 116.4 degrees F and bathroom #2 read at 115.9 deg F. The hot water readings were within the required 105 - 120 degrees.

Clients bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.

Bathrooms have the required grabs bars, non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper.

Medications were locked, centrally stored, and given as prescribed. Medications were reviewed for all (4) clients and facility maintained a 30-day supply of medications.

Clients' medications were reviewed to confirm medication is given as prescribed and is documented properly.

The common areas such as living room and dining room are clean and have the required furniture. Furniture and group activities were spaced to encourage physical distancing.

The backyard does not have a shaded area but chairs and table are provided for clients and visitors. It has been designated as the visitor area for COVID-19 pandemic.

There is a fire extinguisher in the dining room and was observed to be fully charged and last serviced on September 2022.

Smoke detectors/carbon monoxide detectors were present and operable.

The laundry room is located outside and has cleaning supplies inaccessible to residents.

Staff and Clients files were not reviewed during this visit.

Deficiency was cited, exit interview conducted, and copy of the report and appeals rights were provided to the Administrator, Linda WIlliams.