Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by staff and LPA explained the nature of the visit. LPA met with Jessie Nazarreno, direct care professional.

Five clients reside at this facility, LPA was informed three clients were out in the community. At the time of visit there was two clients in care. LPA accompanied with Direct Care Professional began the tour of the inside and outside of the facility. LPA observed required department postings posted on the wall the dining room in the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in the spare refrigerator and freezer located in garage. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in a safe locked storage cabinet located in dining room. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 105.8 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in the garage. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is shaded seating areas for client’s enjoyment. LPA observed a fire extinguisher with service date of October 05, 2023, in kitchen. LPA reviewed five clients’ records. All the required documentation was present and current in client’s files reviewed. The facility P&I records were reviewed. LPA observed that an individual log is maintained for