Facility Evaluation Report

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff called the Administrator (AD) Joshua Estrevillo upon LPAs arrival.

At 8:30 AM LPA Haley began the tour of the facility with staff. LPA Haley observed a screening station right next to the front door with hand sanitizer, face mask, gowns, gloves, and a temperature thermometer mounted on the wall. In the cabinets below the screening station, LPA Haley observed emergency bags for the clients.

There were two clients present for the visit. All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp, plenty of clean linen and storage space. All client bathrooms were clean and well organized. Hot water temperature was measured at 114 degrees Fahrenheit in client bathroom #1(Rm 5), 111.9 degrees Fahrenheit in client bathroom #2 (Hallway),113.5 degrees Fahrenheit in client bathroom #3, and 111.7 degrees Fahrenheit in client bathroom #4.

The kitchen was clean and organized. All knives and sharp objects were locked in cabinet next to the stove. All burners on the stove were operational. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items that were labeled and neatly organized in the kitchen cabinets.

The living room was clean and organized. LPA Haley observed activities for the clients, ipads the clients use, and a karaoke station for the clients to enjoy. Next to the dining room is a locked staff office. In the staff office, LPA observed a computer, printer, a locked bathroom, a locked medication closet, and two locked file cabinets used to store client and staff files. In the staff office was a first aid kit with all the required elements.

During the inspection, LPA Haley observed two fully charged and mounted fire extinguishers. One right outside bedroom #5 and the second extinguisher was mounted on the wall between the dinning room and kitchen.