Facility Evaluation Report

Licensing Program Analyst (LPA) Angelica Rea visited facility to conduct the annual inspection. LPA met with Administrator Joel Alonzo, who assisted with the visit.

There are 4 Units which are the client living quarters. Each unit has 2 stories. On the first floor of each unit, there is a living and dining area, kitchen, a bathroom which is shared by the clients and 2 bedrooms. The clients do not cook in the kitchens. Each bedroom has 2 beds. Upstairs, in each unit, there are 2 bedrooms, a bathroom which is shared by the clients, and a storage closet.

There is sufficient closet & drawer space in the client bedrooms; Smoke detectors were tested and are functioning properly; carbon monoxide detectors were tested and functioning properly; poisons, cleaning solutions, disinfectants are inaccessible to clients; toilets, hand washing and bathing facilities were inspected; LPA observed a sufficient supply of extra linen; personal hygiene items such as soap, toilet paper, toothbrush, toothpaste, and combs are available; sharp knives are locked in the kitchen of unit 4, & inaccessible to clients. Freezers and refrigerators are clean and required temperature is maintained; all clients’ medication were labeled and maintained as required and stored inaccessible to the clients. Hot water temperature was recorded to be 151 degrees F in Unit #3. Fire drill was conducted on 6/3/24.

LPA reviewed 3 client files and 3 staff files. LPA observed needs and services plans, admission agreements, physicians reports with TB test results, as well as other required documents. LPA also reviewed medication on today's visit.

Deficiency cited on 809-D. Exit interview conducted, copy of report and appeal rights were provided.