Facility Evaluation Report

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced for a required one year visit. The LPA met with Director of Operations Hayle Jimenez and Compliance Director Robert Young and explained the reason for the visit. The LPA toured the physical plant to ensure there were no health and safety hazards.

KITCHEN : Knives were kept inaccessible to clients in care. At 12:23 p.m. the LPA observed an unlocked kitchen drawer containing powder dish soap pods accessible to clients in care. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. At 12:25 p.m. the LPA observed two (2) packs of tomatoes that were growing mold. BEDROOMS : Bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted. RESTROOMS : Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 12:15 p.m., water temperature in client bathroom #2 on the 1 st floor measured at 121.8 F. At 12:30 p.m. in visitor/staff/client restroom on the 1 st floor measured at 157.1 F. At 12:38 p.m. in client restroom #1 on the 1 st floor measured 124.3 F. At 12:43 p.m. temperature in the therapist office restroom on the 2 nd floor measured 146.3 F. At 12:47 p.m.in client restroom #3 on the 2 nd floor measured 156.2 F. Client shower door #3 on the 2 nd floor had hard water stains and shower floors had grime build up in the grout. Restrooms were fully stocked. Hand-washing signs were observed in restrooms. COMMON SPACES : Smoke and common monoxide detectors were tested at 12:10 p.m. and were operable at that time. At 12:13 p.m. the LPA observed the smoke detector in client bedroom #1 was missing and not attached. The smoke detector had been removed due to beeping. Medications are stored in the staff office downstairs, at 12:01 p.m. the LPA observed the medication cabinet to be unlocked. Fire extinguishers were fully charged and serviced 6/13/2022. The backyard had furniture and a covered area for client use. There was an in-ground pool, but it was locked and appropriately fenced at the time of the visit. The side gate was self-latching.