Facility Evaluation Report

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry by Administrator Cresencia Santiago.

The facility is a one-story home with four resident bedrooms, two bathrooms, kitchen, dining room, living room, staff room, laundry room, front patio, back yard and attached two-car garage. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Upon first measuring hot water, it measured below 105 degrees Fahrenheit. The Administrator raised the temperature on the water heater. Hot water took an hour to warm up. Hot water measured at 105.4 degrees Fahrenheit and 105.8 degrees Fahrenheit in both bathrooms. LPA advised AD to keep a more frequent water log since water temperatures were so close to the threshold. LPA observed exit gates in the backyard to be operational and unobstructed. Facility has shaded seating areas on the front patio and in the backyard. Smoke and Carbon Monoxide detectors tested operational. LPA observed facility has emergency food and water supply. Appliances are operational. Facility has a 2-day supply of perishable food and a 7-day supply of non-perishable food. Fire Extinguisher was observed to be fully charged as indicated by the built-in meter. LPA observed client medication to be locked in a cabinet in the living room. Staff files were noted to be locked in a closet near the dining area. LPA reviewed medication for all clients and files for two of the four clients. LPA also reviewed P&I. One client's P&I was short by $100. Administrator corrected this during the inspection. A deficiency is being issued on this day. While reviewing files, LPA also noted that the facility has conducted emergency drills in 2023, but the drills did not occur at least quarterly. LPA reviewed all staff files. All clients were away at day program.

Based on today’s inspection, two deficiencies were issued. An exit interview was conducted and a copy of this report was provided.