Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for completing a required annual inspection. LPA arrived at facility was greeted and granted entry by staff. LPA met Marissa Mara, Executive Director and Rey-Philip Genaldo, Clinical, Director and explained the nature of the visit.

Five clients currently reside at this location. LPA accompanied by facility staff began the tour of the inside and outside of the facility, facility is a three-story home. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. LPA toured the kitchen and food storage areas. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food stored in garage refrigerators. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in the medication room in a locked cabinet. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA measured the hot water temperature which measured 109.2 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 and locked in 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