Facility Evaluation Report

Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced required annual visit to the facility. LPA met with Program Director Darlene Emerine and discussed the purpose of the visit. The facility is a Social Rehabilitation Facility (SRF). Licensed capacity of (12) and current census of (11) clients. LPA conducted 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; all bedrooms were equipped with beds, nightstands, chairs, and storage space. LPA inspected client bathrooms; Bathroom showers were operating properly, hot water temperatures tested between at 105.9 and 108 degrees F. LPA observed in a common area: Community Care Licensing complaint poster, facility sketch, activities schedule, emergency telephone numbers, menu, house rules 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.

Record Review: A facility disaster drill was last conducted on 3/14/25 . LPA reviewed (5) client files for admission agreements, medical assessments, and treatment plans. LPA also reviewed (5) staff files for criminal record clearance, training, and health screenings. LPA observed medications were kept in a locked room inaccessible to clients in care. Medications audited at random were labeled and maintained as prescribed.

No deficiencies were cited during today’s visit. An exit interview was conducted with Program Director. A copy of this report was provided to the Program Director Darlene Emerine at the conclusion of the visit.