Facility Evaluation Report

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 11:30AM to conduct an Annual Required inspection, as well as follow up on an Incident Report that was received by Community Care Licensing (CCL) on 1/29/2024. Upon LPA arrival, there were no staff or clients in the facility. LPA made phone calls to let the facility know that they arrived, and House Manager, Bryan Zafra arrived shortly after.

LPA and House Manager initiated a tour of the facility around 12:30 PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 132 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation. House Manager put in a request with Maintenance to come out to facility to turn down the water heater in order to get within the range allowed per regulation. During walk through of the facility, LPA observed a paint can in the side yard.

Extra hygiene products and linens were available. Cleaning supplies are stored in the garage in a closet. The closet was not locked, however there were no clients in facility at the time of visit. Per conversation with House Manager, before clients arrive back to the facility from day program, the garage is locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in the hall closet. Personal Protective Equipment is stored in the office.

Fire extinguishers were last serviced February 2023. Facility smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 11/22/2023. LPA reminded House Manager that these are to be conducted on a quarterly basis.