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) Celia Santos who arrived and was present for the visit. AD Santos has a current administrators certificate that expires 8/2/23.

At 1:20 PM LPA Haley began the tour of the facility with AD Santos. There were three clients present for the visit. There are four client bedrooms in the facility and one client bedroom is vacant at this time. All four client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. In client bedroom #1 the bathroom hot water temperature was measured at 109.5 degrees Fahrenheit. In a hallway closet LPA Haley observed an emergency non-perishable food supply, emergency water, and a disaster kit.

Bathroom 1 was clean and organized, and hot water temperature was measured at 106.7 degrees Fahrenheit. LPA observed a locked cabinet with all the clients hygiene items in the bathroom.

In the living room LPA Haley observed a locked medication closet near the front door. A first aid kit with all required elements was observed in the medication closet. Emergency bags prepared for each client was observed. Furthermore, there was a screening station near the front door with a temperature thermometer, hand sanitizer, and face mask.

The kitchen was clean and organized. All knives and sharp objects were locked in a drawer 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 non-perishable food items

The garage was clean and very well organized. The walkways were free of clutter and tripping hazards. LPA observed an abundant supply of PPE, cleaning supplies, and other miscellaneous items like light bulbs, and batteries.