Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit for an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 (S1) at 8am. LPA met with Administrator, Melba Santos and explained the purpose of the visit.

The facility is a four bedroom, two bathroom, single-story home with an approved fire clearance of three ambulatory and one non-ambulatory. The facility currently has a census of four clients in care. At time of entry, two clients were waiting for transportation to attend Day Programs. One client remained in the bedroom and was not feeling well enough to attend Day Program.

During the visit, LPA observed the fire extinguishers are charged and were checked on November 3, 2025. The last fire drill was conducted on October 1, 2025. LPA obtained client roster, liability insurance documents and reviewed infection control. LPA tested carbon monoxide and smoke alarms and both were operational. The kitchen area was clean and sharps and knives, as well as cleaning supplies, were locked underneath the kitchen sink. The refrigerator and freezer was stocked and there was a variety of fruits and vegetables on the kitchen counter so two-day perishables were available to clients. A weekly menu was observed next to the refrigerator. All appliances were in working order.

LPA toured two of two bathrooms and tested hot water temperatures. The temperatures ranged from 106.3 to 118.5 degrees Fahrenheit. There was plenty of linens and towels. LPA observed four of four client bedrooms and all bedrooms had the required furnishings. LPA observed seven-day non-perishables in the garage with emergency water. A washer and dryer were in working order and there were two freezer units that were full. LPA also observed emergency back packs for the four clients.