Facility Evaluation Report

Licensing Program Analyst (LPA) Samer Haddadin 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 Roslyn Gray, Licensee (LC) and explained the nature of the visit.

During the time of visit, there was one client in care. LPA accompanied with LC 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.

LPA inspected that medication are centrally stored in a safe locked storage cabinet located in laundry unit. 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 between 118.6- and 118.9 degrees Fahrenheit.

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.

During the tour of the kitchen, LPA observed one hammer, 3 sharp screwdrivers and a metal flat scraper in cabinet drawer. LPA also asked LC the whereabouts of sharps and knives; LC stated they were kept on top of a cabinet in one of the rooms and were kept in out of reach however unlocked and in plain view. LPA was able to reach the knives and advised LC to keep all sharps and knives locked and secured out of reach to clients in care.

LPA toured the hallway and observed a Lysol Power Gel in a closed cabinet and was accessible to clients in care. LC immediately locked and secured the Lysol Power Gel.

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 and tripping hazards.(CONTINUE 809C...)