Facility Evaluation Report

Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Faith La arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted and granted entry into facility by Teresita Ringor Direct Care Staff, Cresta Narcise, Caregiver. QA Manager Early Maglaya joined the inspection approximately 10 minutes after LPAs' arrival. Facility Administrator Martin Lopez and House Manager Maltide Ventura joined for part of the inspection.

The facility is a one-story home with three client bedrooms, two bathrooms, kitchen, dining room, living room, backyard and attached 2-car garage. LPAs noted four out of five clients were away at day program. All client rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 105.4 and 107.7 degrees Fahrenheit in the bathrooms. LPAs observed facility has emergency food and water supply. LPAs noted Fire Extinguishers were last serviced on 3/22/2024. LPAs observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen and cabinets in the garage. Knives are locked up separate from toxic chemicals. Medication for each client is kept locked in a closet near the kitchen. The backyard has a shaded sitting/lounging area. Exit gate is unlocked. LPAs observed exit gates to be unobstructed. LPAs reviewed three of the five client files and four staff files. LPAs also reviewed medication for three out of five clients. Facility staff notified LPAs that P & I funds are not kept on the premises. They are kept with the Assistant House Manager. LPAs notified facility staff that P& I funds must be accessible to clients when they want to access it. A deficiency is being issued. LPA noted windows in client rooms to be in disrepair, unused items in backyard, a broken latch on one of the side gates and broken doors on an outdoor storage shed. A deficiency is being issued.

Two deficiencies are being issued based on today's inspection. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility.