Facility Evaluation Report

Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias are conducting this unannounced visit for the purpose of completing an annual required inspection. Upon arrival, LPAs were denied entry into the facility and allowed entry into the garage only. Staff did not provide requested documents or answer LPAs' questions. LPA spoke with Les Johnson who referred LPA to Administrator Deveraux by telephone. LPAs were granted entry into the facility at 7:50 to conduct the physical plant tour. Facility is licensed for six ambulatory clients.

LPAs Lyman and Arias along with Staff Eduardo Manzo toured the facility at 7:59 AM. LPAs toured the physical plant, checked food service, and reviewed medications. The home consists of three client bedrooms, two common restrooms, living room, dining room, and kitchen. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly and shower was free of mold/mildew. Water temperature measured between 113.7 and 115.3 degrees F in facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. At 8:15 AM, LPAs observed exit #4 off the medication room is secured with a lock outside the door preventing the door from opening from the inside. First aid kit had all the required elements. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPAs toured the outside grounds and there is ample shaded seating for clients. Exit gates are unlocked and operational. LPAs reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility does not have documentation of required emergency drills. Facility provides activities in the form of exercise and karaoke. LPAs reviewed medication storage and administration. Medication is being administered per physician order and are stored in an locked medication room. LPAs requested staff and client records. Facility is unable to provide requested documents. Upon arrival to facility, LPAs verified Staff Manzo's criminal background clearance. The staff is not cleared. CONT ON LIC 809C DATED 12/06/2024