Facility Evaluation Report

Licensing Program Analysts (LPAs), Jessica Cho and Celine DePerio made an unannounced visit to conduct the required annual inspection (mitigation). LPAs were greeted and granted entry after completing the COVID-19 screening procedures with Mental Health Tech Trainer, Cynthia Stillman. Administrator (AD) Michael Villarreal arrived on site at 9:36 AM and Melissa Wright arrived approximately at 9:55 AM. The facility is a single-story home with 4 bedrooms, 3 full bathrooms and with a therapy room, office, living room, kitchen, dining room, and a 2-car garage. Facility is licensed for 6 ambulatory clients. As of today, there are 2 clients in care and 10 staff members rotating on duty. Upon arrival, LPAs did not observe the required Coronavirus 2019 (COVID-19) precautionary signs at the front door and entry way. LPAs and licensee toured the interior and exterior of the facility at 9:35 AM and observed the following:

During the facility tour, LPAs did not observe any hazards in the interior and the backyard of the facility. LPAs observed the screen door by the living room had a tear on the bottom right. LPAs reviewed and inspected the FIrst Aid Kit and observed no First Aid Manual. The auditory exit alarms and smoke/carbon monoxide detectors tested operational. The fire extinguishers were charged. LPAs observed medications and sharp objects locked in the office closet. A two day perishable and a seven day non-perishable food items were observed. The stove was lighted unassisted. LPAs inspected the garage which the door was unlocked and additional food, water, emergency supplies, and cleaning solutions were observed. The washer and dryer were in the garage. The cleaning supplies/solutions and PPE were locked in the closet by the entryway. LPAs did not observe a 30-day supply of PPE and did not observe the PUB475 See Something, Say Something Poster in the facility. Common areas were clean and clear of hazards and doorways were free of obstructions.