Facility Evaluation Report

Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct a required annual visit. The LPA met with Administrator Doris Almario and explained the reason for the visit. The LPA toured the facility to ensure there are no health and safety hazards and to ensure regulatory compliance.

KITCHEN : Knives and chemicals are locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. A carton containing 5 dozen eggs was found stored in a kitchen cabinet. Eggs are to remain refrigerated per the food safety guideline label indicated on the front of the egg carton. Administrator indicated the eggs had been bought on Sunday. Eggs were appeared unused, the carton was complete and sealed at the time of the visit. Administrator was reminded to ensure that labels are read appropriately for food storage requirements. BEDROOMS : The facility has six single-occupancy resident rooms and two staff rooms all which were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear and no obstructions were noted. RESTROOMS : Five out of six resident rooms have an en suite restroom and there are two common restrooms, one located in the hallway and the other located in the laundry room. Restrooms were clean and sanitary with grab bars and non-skid surfaces. Between 10:55 a.m. and 11:08 a.m., water temperatures measured between 103.6 F and 113.5 F. Restrooms were fully stocked. Hand-washing signs were observed. COMMON SPACES : Smoke detectors and common monoxide detector were operable at the time of the visit. Fire extinguishers were fully charged however last purchased on 3/31/2021 and in need of service or replacement. The backyard had furniture and a covered area for resident use. The side gate door was self-latching. No bodies of water noted. The LPA observed one dented window screen and multiple windows with spiderwebs and debris. Administrator was reminded to ensure that windows are cleaned regularly. Upon LPA’s arrival it was determined that Staff #1 (S1) was not associated to the facility. The Administrator indicated that S1 was associated to a partner facility however had not had clearance transferred to this facility.