Facility Evaluation Report

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by Alicia Domingo, Caregiver/Activity Assistant. LPA met with Administrator Michelle Domingo and explained the purpose of the inspection.

The facility is one-story with two buildings. The facility has twenty-six resident bedrooms, four common bathrooms, kitchen, dining room, office, medication room, laundry room, living room, courtyard and outdoor lounge space. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. LPA noted clients were lounging or participating in karaoke in the courtyard.

All client rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for clients in the hallway closets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply as well as additional emergency supplies. LPA observed the fire extinguisher was last serviced on May 1, 2024. LPA reviewed an invoice for the facility's smoke alarm/carbon monoxide/sprinkler system stating these items were serviced on 7/10/2024. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen and a closet in the laundry room. Knives are locked up separate from toxic chemicals. Medication for each client is kept locked in the medication room. The courtyard and outdoor seating areas have shaded sitting/lounging areas. Exit gates are unlocked. LPA observed exit gates to be unobstructed. Based on record review, LPA determined the facility conducted one documented disaster drill in the last year. A citation is being issued. LPA reviewed three client files and four staff files. LPA also reviewed medication for three clients. LPA interviewed one staff and two clients.

Based on today's inspection, one deficiency is being issued. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.