Facility Evaluation Report

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 4 clients of which 2 may be non-ambulatory. The facility has 4 clients with 2 present at the facility and 2 others at day programs. Administrator (AD) Nolette Untalan arrived shortly to help facilitate a visit.

LPA along with staff toured the facility at 09:00 AM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of 4 client bedrooms, living room, dining room, and kitchen as well as 4 bathrooms. At 9:05 AM, LPA observed two out of four bedroom door exits to the outside patio closest to the kitchen are non-functional and could not be opened. Evacuation plan marks those exits as evacuation routes. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 109.1 degrees F and 116.4 degrees F in all bathrooms checked. Client bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 01/01/2025.