Facility Evaluation Report

On 9/13/23 at 10:40 am, Licensing Program Analysts (LPAs) Darlene Chavez and Kelly Dulek conducted an unannounced Annual/Required visit. LPA met with Travis Brauker, Operations Supervisor, and Nesha Tandon, Program Director/Administrator, and explained the purpose of the visit.

LPA Chavez toured the facility with the Operations Supervisor and observed the following: Facility is maintained in conformity with state fire marshal regulations. Smoke detectors are hardwired with a sprinkler system. Carbon monoxide detectors are hardwired, tested, and functioning properly. Fire extinguishers were fully charged and last inspected on 6/1/23 and 10/26/22. The pool is surrounded by a fence with a locked gate. Fountains do not contain water. There are no fire arms or dangerous weapons in the facility. Hot water temperatures taken in client bathrooms and kitchen measured between 112.4 F and 127.2 F degrees. Deficiency cited. All toilets and hand washing facilities are maintained in a safe, sanitary, operating condition. The facility is clean, safe, and sanitary. The kitchen has two sinks and two dishwashers. One sink and one dishwasher are inoperable. Operations Supervisor states that the dishwasher has a leak under the dishwasher and sink and they have been inoperable since 9/7/23. Rust was observed on an exterior second story window. Rust area is approximately 2 feet x 2 feet. Deficiency cited. Each client is accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs. There is a minimum 2-day supply of perishables and 7-day supply of nonperishable foods. Food is stored and prepared in a safe and healthful manner. Cleaning supplies were observed in an unlocked cabinet in the laundry room and garden fertilizer in the garden. Deficiency cited. Facility has adequate emergency supplies and first aid supplies. Facility temperature is 73 F degrees. Outdoor walkways are free from obstruction and the facility has outside areas for individuals to use. Centrally stored medication is kept secure in the locked office and inaccessible to clients. Medications are given as prescribed by doctors’ orders.