Facility Evaluation Report

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff contacted Administrators (AD) Melba Santos via telephone who arrived a short time later and was present for the visit.

During the inspection, LPA Haley observed a closet right next to the front door used by staff for their personal items.

Client bedrooms were clean, organized, and had the necessary elements and were in compliance with regulation guidelines. Client bathrooms were clean and organized as well. Hot water temperatures were measured in the range of 109.7 – 116.7 degrees Fahrenheit. Hygiene items are kept locked in the bathrooms due to client behaviors.

The kitchen is clean, organized, and a perishable food supply that meets regulation requirements was observed. A non-perishable food supply that meets regulation requirements was observed as well. Cleaning chemicals are kept locked in a cabinet below the sink. Knives and sharps are kept locked under the countertop next to the locked cabinet with the chemicals. There are additional locked cabinets in the kitchen, above the refrigerator are locked cabinets with clients’ medications and a first aid kit with all the required elements.

A washer and dryer was observed in the laundry area next to the dining room. In hallway closet, additional nonperishable food items were observed. In the locked hallway closet, LPA Haley observed a locked box with clients P&I funds. An emergency supply of water, food items, and emergency bags for clients was observed in the locked closet.

The garage remains locked and inaccessible to clients at all times. The garage was organized, free of clutter and walkways are free of obstruction. An additional refrigerator with an additional food supply, a supply of diapers, additional linens, and an extra wheelchair was observed in the garage.