Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit to complete the annual inspection required. LPA arrived at the facility was greeted and granted entry by staff. LPA met with Whitney Buss, Compliance Manager Manager and explained the nature of the visit.

Six clients currently reside at this location, all clients were present at the time of visit. LPA accompanied by Compliance Manager began the tour of the inside and outside of the facility, facility is a two-story home. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. LPA toured the kitchen and food storage areas. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food stored in garage refrigerators. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in the nurse’s station and all cabinets that are used are kept locked. Entry door to unit is always kept locked if a staff member is not in the unit. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA measured the hot water temperature which measured 113.5 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored and locked in garage and in a cabinet located in the kitchen. The facility has an available clean supply of linens. LPA inspected the client’s bedrooms, which has sufficient lighting to ensure safety and comfort. All bedrooms are observed to have all the required components. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of