Facility Evaluation Report

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an Annual Inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that thirty-one (31) clients are enrolled at this facility and there are currently eight (8) staff. The facility has an Infection Control Plan on file.

LPA Delgado interviewed of five (5) client interviews and five (5) staff interviews.

Client Records/Incident Reports/Personal Rights/Information- LPA began review of client records. Five (5) records were reviewed. LPA reviewed for admission agreement, needs and services plan, IPP, medical assessment and TB test results, identification and emergency information, client rights notification and register of clients.

Personnel Records/Training/and Staffing- LPA began review of employee records. Five (5) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance, exemptions, transfer of a criminal record clearance, health screening and TB test results, (8) hours training verification, Administrator continuing education (30) hours every 24 months.

Food Service- Food prep areas are clean and organized. Snacks food items are stored in the kitchen. Emergency food is not sufficient and water supply is present. There is a locked location for chemicals. Sharps locked inside a cabinet with a Ajax observed in the kitchen and sharps for office use are locked in offices.