Facility Evaluation Report

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of

conducting a required annual inspection. LPA was greeted and granted entry into facility by Administrator (AD) Roland Olegario.

The facility is a one-story home with three client bedrooms, one bathroom, kitchen, dining room, living room, staff office/quarantine room, staff room with staff bathroom, backyard with pool and attached 2-car garage. Facility appears clean, safe and sanitary. LPA noted all clients were away at Day Program. All client rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens for clients in the hallway closet. Restroom is stocked with soap and paper towels and has hand washing postings. Hot water measured at 116.6 degrees Fahrenheit. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was last serviced on February 8, 2024. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the entryway closet and the garage. Knives are locked up separate from toxic chemicals. Medication for each client is kept locked in a closet in the entryway. The backyard has two shaded sitting/lounging areas. Exit gates are unlocked and self latching. LPA observed exit gates to be unobstructed. LPA observed the pool to be inaccessible to clients. There is a chain-link fence blocking access to the pool on one side. The fence is 5 feet tall with no space underneath it. The fence has a door with a locked latch. There are 2-inch by 2-inch openings in the shape of diamonds across the entire fence. The pool's other three sides are surrounded by the backyard's 5-foot 8-inch tall brick walls. AD stated the pool is 6 feet deep at it's deepest. LPA reviewed two client files and the staff files. LPA also reviewed medication and P&I for two clients. LPA interviewed one staff member. Clients were all away from the facility and unavailable to be interviewed during the inspection. During record review, LPA observed the facility's Emergency Disaster Plan (LIC 610E) was not fully filled out. AD filled out any unanswered questions on the 610E and presented it to LPA during the inspection

No deficiencies noted during today's inspection. An exit interview was conducted and a copy of this report was provided to the facility.