Facility Evaluation Report

Licensing Program Analyst (LPA) Magda Malcore made an unannounced required annual visit to the facility. L PA met with Susan Abou-Hebeish, Administrator a nd discussed the purpose of the visit. The facility is a Social Rehabilitation Facility (SRF). Licensed capacity of (16) and current census of (11) clients. Facility is operating in ratio. LPA conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: LPA observed indoor and outdoor passageways are kept free of obstructions. The facility has sufficient indoor and shaded outdoor space for client activities. The facility has no bodies of water. The facility has a sufficient supply of bed linen, towels and personal hygiene products for clients in care. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; bedrooms were equipped with beds, nightstands, chairs, and storage space. LPA inspected client bathrooms; Bathroom showers are equipment with grab rails and hot water temperatures tested between at 105 degrees F. LPA observed in a common area: Community Care Licensing complaint poster, disaster evacuation plan, and personal rights posters. LPA observed cleaning supplies, toxins, and sharps were kept locked and inaccessible to clients in care.

Food Service: LPA observed a sufficient supply of non-perishable and perishable food for clients in care. Food was stored in a safe and healthful manner. Kitchen hot water temperature tested at 108 degrees F.

Record Review: A facility fire drill was conducted on 10/3/23. LPA reviewed (4) client files for admission agreements, medical assessments, and needs and services plans. LPA also reviewed (4) staff files for criminal record clearance or exemptions, training, and health screenings. LPA observed medications were kept in a locked cabinet inaccessible to clients in care. Medications audited at random were labeled and maintained as prescribed.