Facility Evaluation Report

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Administrator (AD) Mariles Borja and discussed the purpose of the inspection.

During the inspection LPA and Staff Michelle Santos conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and observed the following:

This is a single-story compound consisting of five cottages. Cottage one accommodates (12) clients, cottage two accommodates (4) clients, cottage three accommodates (10) clients and cottage 4 accommodates (6) clients. The fifth cottage is used as staff bedroom with an attached food storage room. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. There is a shaded sitting area. LPA observed clients in their bedrooms and throughout the facility, engaging in leisure activities, such as make-up, coloring, and watching television. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 105.0-118.5 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted in common areas in each client cottage. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers were observed to be fully charged. Facility appliances were all inspected. One out of five refrigerators was leaking fluid and puddling at the base. One out of five stove burners tested inoperable, and staff attempted to ignite using a grill lighter; a Deficiency was cited on today’s date. Sharps were observed locked in the kitchen. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication carts were observed to be locked and lock is operational. The first aid kit has all the required elements. LPA reviewed six client files and four staff files. LPA interviewed five clients and three staff. (Cont. LIC809-C)