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) Susierose Abella arrived and was present for the visit. AD Abella has a current administrators certificate that expires 8/18/22.

At 11:18 AM LPA Haley began the tour of the facility. There were two clients, two staff and AD Abella present during the visit. LPA Haley was screened and temperature checked at the entrance of the facility. LPA Haley observed a screening station set up with a temperature thermometer, temperature log, and pre screening questionnaire. Right near the entrance of the facility there is a locked medication closet, first aid kit, surgical mask and other supplies.

Five of six client bedrooms were clean, organized, and had all necessary requirements. There was one vacant client bedroom with only a dresser. Currently that bedroom is not being occupied. In client bathrooms #1 hot water temperature was measured at 105 degrees Fahrenheit. At 11:27 AM LPA Haley observed rust present in the shower area in client bathroom #1. LPA Haley advised AD Abella of keeping the shower clean and sanitary at all times. Bathroom #2 is used by staff, and remains locked; however, clients are allowed to use bathroom #2 when staff is present. In bathroom #2 hot water temperature was measured at 113.7 degrees Fahrenheit.

In the locked garage, LPA Haley observed an emergency food and water supply, as well as emergency supplies for all clients prepared and ready to go. All hazardous chemicals and cleaning materials are kept in a locked cabinet.