Facility Evaluation Report

On 05/16/2024 at 8:29 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with lead housekeeper, Dominador Episcope who then called the House Manager, Cora Episcope. House Manager Cora and Hyacinth Hogan assisted LPA Lee with today’s annual inspection visit. The current census is 30 with 7 facility staff.

This facility is a single story building licensed to serve thirty-six (36) ambulatory mentally disabled clients. LPA Lee inspected the physical plant including but not limited to the 3-living area, lobby area, craft area, sitting/TV room, kitchen, dining area, 8 client bedrooms, 3 client bathrooms, laundry room, live in staff rooms and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured in client bathroom #1 at 90.1 degrees Fahrenheit and client bathroom #6 at 91.1 degrees Fahrenheit which is not within the required regulation of 105 to 120 degrees Fahrenheit. During today’s visit, House Manager adjusted the water temperature and LPA Lee rechecked both client bathrooms. Client bathroom#1 water measured at 106.3 degrees Fahrenheit and client bathroom #6 measured at 105.8 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. One of the extinguisher is located in kitchen and 7 other fire extinguishers are located throughout the facility hall which leads to clients’ bedrooms. Fire extinguisher was last serviced on 01/17/2024. The last fire drill was conducted on 03/14/2024. LPA Lee observed the facility has a has a public telephone in the lobby area for client to use.