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 Isidro Calub, Administrator and LPA explained the nature of the visit.

Four clients reside at this facility, upon arrival one client was being dropped off from day program and three clients remained out in the community. LPA accompanied with Administrator began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. LPA toured the kitchen and was informed kitchen cabinet had been remodeled over the weekend and LPA observed kitchen supplies were being placed back in the kitchen. LPA observed food supply was already placed in the kitchen refrigerator and pantry. There is a minimum of one week of non-perishables foods and two days of perishables foods available. LPA observed meal being prepared for dinner at the time of visit. Additional food storage located in garage refrigerators. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in a safe locked storage cabinet located in dining room. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care, only two clients currently take medication. LPA measured the hot water temperature which measured 109.9 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. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. 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 shaded seating areas for client’s enjoyment, there is additional covered seating in front patio for clients. Fire drills conducted every three months and LPA verified last Fire Drill was conducted on March 31, 2023. LPA began review of records.