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. Administrator (AD) Melba Santos was present for the visit and she has a current Administrators certificate that expires 06/30/24.

At 1:08 PM LPA Haley began the tour of the facility with AD Santos. There were three clients present for the visit. All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. Both client bathrooms were clean and organized. Hot water temperature was measured at 110.8 degrees Fahrenheit in client bathroom #1 and 116.7 degrees Fahrenheit in client bathroom #2. In a hallway locked hallway closet LPA observed plenty of clean linen and hygiene supplies. In the hallway closet near the living room LPA observed a well stocked supply of nonperishable food items.

In the living room, LPA observed a locked file cabinet with client files, staff files, and on top of the file cabinet is a lock box for families to write concerns or grievances if needed. A screening station with a temperature thermometer, screening log book, hand sanitizer and face mask was observed at the entrance of the living room near the front door.

The kitchen was clean and well organized. All hazardous chemicals, knives and sharp objects were locked under the sink. There's a locked cabinet used to store client medication, and multiple first aid kits with all required elements was observed in the locked medication cabinet. 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. On the side of the refrigerator, LPA observed a closet full of additional nonperishable food items. A fully charged fire extinguisher was mounted near the sink.