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. LPA Haley was screened and temperature checked upon entering the facility. Administrator (AD) Cristina Ong was notified via telephone and arrived for the visit.

At 2:50 PM LPA Haley and AD Ong began the inspection at the entrance of the facility. There is a fully charged fire extinguisher mounted on the wall next to the front door. A screening station with hand sanitizer and screening logs was observed right next to the front door. There were four clients present during the visit. Near the front door there's a staff room that remains locked.

Clients bedrooms were clean, organized, and had all necessary requirements: night stand, chair, lamp and storage space. Client's bathroom were clean and organized. Hot water temperature was measured at 105.2 degrees Fahrenheit in bathroom #1 and 106.8 degrees Fahrenheit in bathroom #2. In the hallway closets near the client rooms, LPA observed plenty of clean linen and additional cleaning supplies.

The kitchen has an small office space set up in the corner. Client medication, and a first aid kit with all required elements is locked in a cabinet near the refrigerator. LPA Haley observed a 2 day supply of perishable items and a 7 day supply of non-perishable items. An emergency food and water supply was observed in the kitchen. There's a staff room near the kitchen that remains locked and all client and staff files are in a file cabinet in the staff room.

The backyard had clear walkways, free of tripping hazards. Both side exit gates were self closing and self latching. LPA Haley observed a shaded patio area with tables, chairs, a treadmill and stationary bike for clients to enjoy. There's a locked cabinet in the patio area with plenty of PPE supplies. Two locked storage sheds were observed in the backyard. One shed was used to store miscellaneous supplies for the facility, and the second shed was used to store tools, cleaning supplies and other items.