Facility Evaluation Report

Licensing Program Analysts (LPAs) Julie Florio and Chris Arnhold arrived unannounced, to conduct a required 1-year annual inspection and were greeted by House Manager, Rowena Radana. Administrator, Jenero Jefferson was not present. House Manager contacted Administrator but he did not show up during the inspection. LPAs informed House Manager that the facility administrator shall be present a sufficient number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.

LPAs initiated a tour of the facility around 9:00pm and observed the following: Facility was a comfortable temperature and passageways were free from obstructions. Water temperature in clients' bathroom measured at 110.8 degrees F which is within allowable range of 105 to 120 degrees F. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked.

Fire extinguisher was last serviced May 2023. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular disaster drills and the most recent drill was conducted January 2024.

At approximately 10:00am five staff files and five client files were reviewed. Staff have required First Aid and CPR certificates. All staff are missing documented training from a licensed professional for assisting client(s) with inhaler medications. Medications and medication records were reviewed as well as client P&I. Review of facility's Surety Bond showed that client P&I exceeds the amount covered on the Surety Bond. LPAs discussed with House Manager the need to increase the surety bond amount. LPAs observed one resident missing a care plan necessary to address behaviors.