Facility Evaluation Report

Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. On today’s visit the LPA met with Administrator, Neil Jabonero; he was notified of the purpose for the visit.

INFECTION CONTROL: The facility has an infection control plan in place that is being reviewed regularly for any needed updates and/or changes. The Administrator reported the plan is being followed by staff whenever there are any clients in care who present with infections. PHYSICAL PLANT AND ENVIRONMENTAL SAFETY: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Clients appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. No pool or other body of water was observed on the property. The Administrator reported there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. The smoke and carbon monoxide alarms were tested and found to be operable. The interior and exterior areas of the home were observed to be very clean and safe. Operational Requirements: The Licensee has secured and appears to be maintaining the approved fire clearance. Proof of training in reporting requirements was observed on file. The licensee appears to be providing for all client's activities of daily living needs, including supervision. A plan for providing clients with activities is being followed. STAFFING: Facility personnel appear to be competent to provide the necessary services to meet individual client needs. Review of the facility's staff schedule revealed two staff members are scheduled per shift. Per Administrator, two to three staff are scheduled at a time. He reported there is currently sufficient staffing available to meet client needs. Administrator reported night staff are available to provide clients with care and supervision. He reported night staff are on call and on the premises, as required. Staff are trained in emergency procedures. PERSONNEL RECORDS - TRAINING: The Administrator appears to be on the premesis sufficient number of hours to