Facility Evaluation Report

Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced at approximately 9:30AM to conduct an Annual Required inspection and was greeted by Administrator Manilia Baujour. LPAs and Administrator discussed the purpose of the visit.

LPAs and Administrator initiated a tour of the facility around 09:45 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. LPAs observed restroom to be equipped with two sinks. Faucet lever for hot water was not functional on one of the sinks. Water temperature in sinks accessible to clients measured at 70 and 125 degrees F which is not within the range of 105 to 120 degrees F 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 hallway closet. Personal Protective Equipment is stored in the garage.

Fire extinguishers were last serviced May 21, 2023. Facility has smoke and carbon monoxide detectors located throughout the facility that were tested and operational during inspection. Most recent fire/disaster drill was conducted 03/02/2024. Client cash resources could not be reviewed during inspection.

Four staff files and four client files were reviewed. 3 of 4 staff have required First Aid and CPR certificates. Remaining required documents could not be located by LPAs and Administrator. 4 of 4 clients did not have Medical Assessments or TB on file. 4 of 4 clients did not have updated Needs and Services Plans on file.