Facility Evaluation Report

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Karen Saturno and discussed the purpose of the inspection. Administrator (AD) Consolacion S Burgos was not present during the inspection.

LPA reviewed Infection Control requirements. At about 8:30AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 2-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 3 staff and 2 clients present at the facility. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 110 degrees F in the hallway bathroom and 109.9 in the bedroom bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked under the kitchen sink and in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. LPA discussed the facility’s licensing fees with S1. At about 9:00AM, LPA reviewed 4 client files and 5 staff files, interviewed 2 clients and 3 staff, inspected medications for 4 clients, and inspected client money and ledgers for 4 clients.