Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman made an announced pre-licensing visit. LPA identified herself and discussed the purpose of the visit with Licensees/ Administrators Mark Alipio, Davina Alipio, and Myrna Alipio. An initial application to operate an Adult Residential Facility was submitted to CCL on 11/04/2021 for a capacity of 4 ambulatory residents. Administrator Mark Alipio has a current administrator certificate expiring on 01/02/2023. There are no clients in care during today's visit. Facility has covid signage in the facility and LPA observed the screening/ sanitation station in the entrance of the facility.

LPA Lyman along with Licensee/ Administrators toured the facility at 9:10 AM and observed the following:

Structure: Facility is a one story, 4 bedroom, 2 bathroom house with an attached garage and a light creme exterior. The exit gates are closed and unlatched. Living Room/ Dining Room : Adequate seating is available in the dining room, living room, and family room. Bedrooms Clients: All bedrooms are single occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All client restrooms have a working toilet/ wash basin as well as paper towels in all restrooms. There is a non-skid surface in bath/ shower. There are hand washing signs in all restrooms. Linens & Hygiene Supplies: Linen supply is in ample supply for clients in care. Emergency Phone Numbers and Exit Plan: Posted in the entrance area of the facility. Food Service: Facility has ample 7 day non-perishables/ 2 day perishables in the kitchen. LPA observed a sample menu. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are fully charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins : Stored in a locked area in the kitchen with the sharps. Water Temperature: Tested and recorded between 118 and 120 degrees F.in facility bathrooms. Emergency Supplies: LPA observed ample emergency food, water, and emergency supplies. Facility has the emergency disaster plan posted and has completed the mitigation plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. LPA observed a first aid manual. Medication to be stored and locked in a locked cabinet in the living room. Facility uses a medication administration record. CONTINUED ON LIC 809C DATED 11/19/2021.