Facility Evaluation Report

On May 14, 2025, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by Administrator Lourdes Steagall and granted entry after stating the purpose of the visit. Administrator (AD) Lourdes Steagall was present to assist with the facility inspection on today's date.

The facility is licensed for four (4) ambulatory Developmentally Disabled Clients with approved hospice waiver for one (1) Client. Facility is a level 4 D Adult residential facility. Currently, there are three clients present during today’s visit.

This is a single story with a two-car garage facility. The facility has four client bedrooms, two staff rooms and four bathrooms.

At around 7:50AM, LPA conducted a tour of the physical plant accompanied by Administrator Lourdes Steagall, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 116.2 degrees F. A comfortable temperature of 70 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Two fire extinguishers was charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance. LPA did a review of clients Personal and Incidental (P&I) Funds and monies were complete. CONTINUED ON 809C