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) DIvina Alipio via telephone who arrived and was present for the visit. AD Alipio has a current administrators certificate that expires 11/2/23.

At 10:35 AM LPA Haley began the tour of the facility. There were three clients present during the visit. In the living room LPA Haley observed a screening station near the front door with a temperature thermometer, screening log books, hand sanitizer, mask, face shields, and gloves. There is an office set up in in a section of the living room with two file cabinets used to store staff files, supplies for the clients, and a P&I drawer that remains locked. There's a shelf with client files and a first aid kit with all the required elements.

All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. All client bathrooms were clean and organized. Hot water temperature was measured at 108.2 degrees Fahrenheit in client bathroom #1, 113.5 degrees Fahrenheit in client bathroom #2, 113.9 degrees Fahrenheit in client bathroom #3 112.1 degrees Fahrenheit in client bathroom #4. In client bedroom #2 the closet door has been removed due to his behavior.

The kitchen was clean and organized. All knives and sharp objects were locked in a drawer near the stove. Three of four burners on the stove were operational. LPA Haley advised AD Alipio of the importance of the facility being in good repair at all times. There was a fully charged fire extinguisher mounted near the sink. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items. All hazardous cleaning chemicals are locked under the sink. There's a closet in the kitchen that's used to store cleaning supplies, and a locked medication cabinet was observed.