Facility Evaluation Report

On 08/12/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Marivic Abat, Direct Support Professional (DSP), where LPA explained the purpose of the visit. The Administrator Omar Talla, was unable to come to the facility. At the time of the visit there was (2) staff and (2) clients at the facility. LPA followed up on the annual fees that are due on or before 08/18/25, and provided the following PIN 747457, in the event that the fees are paid electronically. LPA verified contact information and the governing body was observed to be in good standing.

The facility was observed to be clean and the passageways being free from of any obstructions. There are no pools or bodies of water on the premises, or guns and ammunition. The facility emergency disaster drills are being conducted on a monthly basis, last drill was on 07/18/25. The fire extinguisher was observed to have the tag in tact, last serviced in May 2024. The smoke and carbon monoxide detectors were tested and found to be operable. The medications, sharps and chemicals were observed to be locked and inaccessible to clients in care. The hot water was tested and measured to be at 113.9 degrees Fahrenheit.

The facility was observed to have the required postings such as CCL complaint poster, emergency disaster plan and personal rights. The client rooms were observed to have the required furniture, and the facility was in observed to have personal hygiene supplies for client use. The facility is equipped with emergency supplies as well as grab bars and skid mats inside the bathrooms. All three (3) client's personal and Incidental funds were reviewed with no discrepancies found. The Medication Authorization Records MARs were complete with initials and explanations for PRN usage.