Facility Evaluation Report

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:00AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit. House Manager, Elizabeth Ramos arrived shortly after.

LPA and staff initiated a tour of the facility around 09:15 AM 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 121 and 122 degrees F which are not within the range of 105 to 120 degrees F allowed per regulation. Maintenance is scheduled to come out to facility during the day of inspection and will be slightly turning down the water heater in order to get within the range allowed per regulation.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were 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 garage. 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 01/05/2024. Client cash resources were reviewed. Three staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Administrative Certificate for Administrator, Maria Lepe (6061120735) expired on 11/29/2023 but is on the departments pending list awaiting renewal.