Facility Evaluation Report

Licensing Program Analyst (LPA) E.Conchas conducted an unannounced visit to the facility for the purpose of an annual inspection. LPA met with the Program Director Toni Yanes.

LPA toured the facility inside and out. The facility has no bodies of water. O utdoor and indoor passageways were kept free of obstruction . Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Centrally stored medications were kept in a safe an d locked place. LPA toured the storage area. Food was stored in a safe and healthful manner. The facility had a an emergency food supply and food to provide snacks .

Licensee did not have an authorized representative. A deficiency was cited. LPA did not have access to administrator file. A deficiency was cited. Facility has a designated area for client, staff and facility files. LPA reviewed clients files for admission agreements, updated physician reports, and needs and services plans. One client was missing their Individual Program Plan. A technical violation was issued. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA observed staff were not associated with the facility how ever were finger print cleared. A technical violation was issued. Staff 1 was missing copy of training completion. A technical violation was issued. Staff 2 file was missing AED training completion. A technical violation was issued. Facility Infection control plan training was not updated a Technical Assistance was issued. The facility has charged fire extinguishers. A fire clearance was provided for smoke detectors but could not provide or verify operating carbon monoxide detectors. A deficiency was cited.