Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by Ann Amante, Administrator and LPA explained the nature of the visit.

Five clients reside at this facility, LPA was informed all clients were out in the community. LPA accompanied with Administrator began the tour of the inside and outside of the facility. LPA observed required department postings posted on the wall of facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 105.6 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 locked in a hallway. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all 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 obstructions. LPA observed there is seating areas for client’s enjoyment. LPA observed a fire extinguisher with service date of September 20, 2023, in kitchen. Fire drills are conducted monthly, and LPA verified last Fire Drill was conducted on November 12, 2023. LPA began review of records. LPA reviewed five clients’ records. All the required documentation was present and current in the client’s files reviewed. The facility P&I records were reviewed. LPA observed that an individual