Facility Evaluation Report

Licensing Program Analyst (LPA) Javier Prieto and LPA Becky Mann visited the facility unannounced to complete a comprehensive annual inspection. LPA Prieto met with Administrator Milagros Samson and explained the purpose of the visit. Today’s inspection included a facility tour, record reviews, and interviews with staff. Residents in care were unable to participate in the interview process.

The facility is seven (7) and four (4) bathrooms of which three (3) bedrooms and two (2) bathrooms are used for residents in care. The facility also has great room, dining area, living room/loft area, covered patio, and attached garage. Licensed capacity is four (4), and the facility is at maximum capacity.

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility temperature is 77 degrees Fahrenheit. LPA inspected resident bedrooms; each room included required furniture such as mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were functional. LPA Prieto observed adequate furniture and lighting throughout the facility. The hot water temperature tested within regulation at 114 to 115.5 Fahrenheit. The facility has operating smoke detectors and carbon monoxide alarms, which LPA Prieto tested during the visit. The facility has a charged fire extinguisher. LPA Prieto observed personal rights posters, licensing documents, and the disaster plan posted throughout the facility. LPA Prieto observed that cleaning supplies, toxins, sharps, and other dangerous items are kept secure and inaccessible to residents in care. There was a designated storage space for client/staff files. LPA Prieto observed medications locked and inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.