Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to the facility for a Required Annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA met with Administrator Rosario Maniquis. At the time of the visit, all clients were out of the facility at Day program.

LPA toured the facility inside and outside. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 4/26/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the storage and laundry areas. Centrally stored medications were kept in a safe and locked closet. LPA toured the client bathrooms. LPA measured the hot water temperature in the bathroom which measured 121 degrees Fahrenheit. LPA observed emergency supplies in the hallway closet. The outside of the facility had a shaded area with a table and chairs. The facility does not have a pool or bodies of water.

LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification including the Administrators HIV/TB training. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Facility has secured each consumer’s personal property and cash resources. All required signs and postings were visible in a common area with the exception of the facility Visitation Policy. Administrator stated it is incorporated in the facility plan, and will post it in a public area. Deficiency issued. LPA observed the LIC 610D was outdated, from 2015. Per Administrator, there are no changes to the plan. Technical Assistance provided. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.