Facility Evaluation Report

Licensing Program Analysts (LPAs) Kimberly Lyman and Samer Haddadin conducted an unannounced visit to conduct the annual required visit. LPAs were greeted and granted entry into the facility and explained the reason for the visit. Facility is licensed for 42 ambulatory clients. Lucy Brimbuella has an Administrator Certificate expiring on 06/02/2025. The facility appears clean and sanitary.

LPAs Lyman and Haddadin along with Administrator Lucy Brimbuella toured the facility at 1:05 PM. LPAs toured the physical plant, checked food service, and reviewed facility documentation. Facility consists of 8 buildings. One building is for administration, one is an activity room and one is a multipurpose room. The 5 remaining buildings, or bungalows, are for clients. Each bungalow consists of one living room, two or three client rooms and a bathroom. 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, and shower was free of mold/mildew. Water temperature measured between 106.5 and 109.7 degrees F in facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including thermometer, tweezers and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and fire extinguishers are inspected quarterly by an outside company with the last visit conducted on 05/14/2024. Carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. LPAs toured the outside grounds and there is ample shaded seating for clients as well as outside activity areas and garden. LPAs observed ample emergency food and water supply. LPAs reviewed the emergency disaster plan as well as infection control plan during the visit. Plans are thorough and complete. Facility provided documentation of last fire drill conducted on 08/05/2024 and drills are conducted quarterly. Facility provides activities in the form of games, exercise and facility social events. At 1:45 PM, LPAs reviewed five client files and fours staff files. Client files contained required documents including admission agreements, physician reports and client appraisals. Staff files reviewed contained required documentation of training and all pertinent paperwork. CONTINUED ON LIC 809C DATED 08/06/2024.