Facility Evaluation Report

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Required - 1 year inspection. LPA was greeted and granted entry into the facility by Direct Support Professional (DSP) Bryan Barras and reason for the visit was explained. Administrator's (AD) Certificate for Deborah Seifert expires on 12/23/2024. Per AD Seifert, she has completed the renewal process. There was one client present and four clients at Program during today's visit. LPA, along with DSP Barras toured the physical plant. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked and toilets and water faucets worked properly and shower was free of mold/mildew. Hot water temperature was within regulatory requirements. Client bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen is clean and organized. Perishable and non-perishable food supply was checked and adequately stocked. Appliances are operational during today's visit. LPA observed sharps and cleaning supplies are inaccessible to the clients. Smoke detectors and carbon monoxide detectors tested operational; Fire extinguisher was fully charged and mounted. No bodies of water were observed outside. Walkways around the home were clear of hazards. Exit gates are unlocked. LPA observed First Aid kit contained required items. Last Emergency Drill was conducted on 12/04/2024 and are conducted monthly. LPA observed emergency supplies including food and water in the garage. LPA reviewed five client files and two staff files. Client and staff files contained required documentation. Medication was observed to be in a centrally stored location and medication reviewed appeared to have been dispensed accurately. P & I money matched facility ledger. Liability and Surety Insurance certificates are current. LPA observed board games, exercise stationary bike, and books for Clients use. DSP Maria Henriquez arrived at 1pm to relieve DSP Barras.

Based on observations made during today’s visit, no deficiencies are being cited. This report was discussed with DSP Henriquez and a copy of the report was sent to email on file.