Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Luis DeJesus.

The facility is a four client bedroom, one staff bedroom, level 3 , single story residential home with an approved fire clearance of four ambulatory and two non-ambulatory residents . The facility currently has a census of six clients in care. At the time of visit three clients were present and three were at Day Program.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two client bathrooms, and testing auditory devices on all exits . The hot water temperature measured between 114.2 to 115.5 degrees Fahrenheit and all smoke detectors were operational . The fire extinguisher is charged and was serviced on September 13, 2024. The facility’s last fire drill was conducted on March 1, 2025 . LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand . LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. The First Aid Kit also had all the required elements.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of client records. Client P&I records were reviewed and were accurate. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on August 31, 2025.