Facility Evaluation Report

Licensing Program Analyst (LPA) Nancy Guillen conducted and unannounced visit for the purpose of completing a required annual inspection. LPA arrived at the facility and was greeted and granted entry by Lead Mental Health Worker, Carly Amaro after explaining the nature of the visit. LPA met with Program Director (PD), Denita Trowel and began the tour of the facility.

Five clients currently reside at this location, all were away at their day program and returned to the facility for their meditation session with Guillermo Da Silva-Montemayor, Associate Clinical Director. LPA accompanied by Program Director, began the tour of the inside and outside of the facility, facility is a one 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 refrigerator and in emergency storage in hallway closet. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a locked hallway closet. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA measured the hot water temperature which measured 80-130 degrees Fahrenheit; a deficiency was cited on today’s date. 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 the garage. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which have sufficient lighting to ensure the safety and comfort of clients. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. Smoke detectors and carbon monoxide were tested and found to be operational.