Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/15/2023 at 09:18 a.m. LPA was granted entry and met with Staff, Sadat Abdul Kadir, who was informed of the purpose of the visit. LPA spoke with the administrator, Queen Omeje over the phone during the visit. At the time of the visit there was (1) staff and (0) clients present.

The facility is a one story home with (5) bedrooms and (3) bathrooms with attached garage. No inground pools or firearms are being kept at the facility. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff interviews. Clients were out in the community at their day program during the visit.. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.

Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. LPA observed in the master bedroom that in a walk -in closet, sheets and pillow were found on the floor of the closet as a makeshift bed. Staff informed LAP that the room was being used by facility staff. When LPA asked the administrator, they stated they were unaware of this occurring at the facility. This poses an immediate health, safety or personal rights risk. LPA documented Type A deficiency for this, and documented plan of correction with administrator over the phone. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients in pantry closet. The smoke detector and carbon monoxide was operational, and the hot water temperature 106.8F. The back yard has an above ground hot tub which is covered and made inaccessible to clients by a locked gate in the facility side yard.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision / Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate.