Facility Evaluation Report

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Matthew Nazareno and discussed the purpose of the inspection.

LPA reviewed Infection Control requirements. At about 12:15PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and storage areas and observed the following: Structure: facility is a medium-sized commercial facility. Facility is composed of one building which contains 27 client bedrooms, multiple private and common bathrooms, multiple common areas, a kitchen, a dining room, a laundry room, a medication room, an office, and multiple storage closets. There is a back yard with a patio cover for the clients. LPA observed 5 staff and multiple clients present at the facility. LPA inspected 15 out of 27 client bedrooms. Client Bedrooms: the 15 client bedrooms inspected are spacious and will easily accommodate the clients’ furnishings. Furniture for 15 client bedrooms inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 and 120 degrees F in the 6 client bathrooms tested. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage closets. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 11:15AM, LPA reviewed 6 client files and 4 staff files, interviewed 4 staff and 6 clients, inspected medications for 6 clients, and inspected client money and ledgers for 6 clients.