Facility Evaluation Report

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by LVN Angela Guido. Administrator Sean Estrella joined the inspection at approximately 1:45pm.

The facility is a one-story home with five bedrooms, three bathrooms, kitchen, dining room, living room, family room, backyard and attached 2-car garage. Facility appears clean, safe and sanitary. LPA noted one client was away at Day Program at the time of inspection. LPA also noted the facility's water heater was being serviced at the time of the inspection. LVN stated the facility staff observed the water heater was not producing hot water on 1/31/2024 and scheduled the water heater to be serviced on 2/1/2024. All residents rooms had required elements, including bed, chair, closet space and ample lighting. One bedroom was converted into a staff office. One bedroom is temporarily being used for storage until the facility admits a fourth client. Facility had extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water could not be measured due to water heater service. LPA reviewed facility's water log and noted water temperatures on 1/4/24, 1/11/24, 1/18/24 and 1/29/24 were between 105 degrees Fahrenheit and 120 degrees Fahrenheit. LPA observed facility has emergency food and water supply. LPA observed the fire extinguishers were last serviced on 9/7/23. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen and the garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet near the kitchen. The backyard has two shaded sitting/lounging areas. Exit gates are unlocked and self latching. LPA observed exit gates to be unobstructed. LPA reviewed all three client files. LPA also reviewed medication for all three clients. Facility has board games, exercise equipment, a Ms. Pacman Arcade game, Jukebox and more for client use. Emergency contacts, Menu and Calendar are posted and available for review.

No deficiencies noted during today's inspection. An exit interview was conducted and a copy of this report was provided to the facility.