Facility Evaluation Report

Licensing Program Analyst (LPA), Marisela Garcia-Centeno, made an announced Pre-licensing and Component III visit to the facility. LPA met with Administrator Yoanne Chrisostomo and allowed entry into the facility after identifying herself and stating the purpose of the visit. The facility is undergoing a change of ownership. The facility was approved for four (4) adults ages 18 through 59, four (4) of whom may be ambulatory only. The Fire Clearance for this application was approved on 3/31/2022.

LPA toured the facility inside and out. The facility has four (3) resident rooms and a staff room. There are three bathrooms in the home for resident use. The three (3) resident bathrooms are located adjacent to residents' rooms and were equipped with grab bars and non-skid mats. The kitchen is fully stocked and has a two-day supply of perishable and seven-day supply of non-perishable foods. All the appliances are in working order. Medications were observed to be in a safe and locked area. Resident and staff records are locked in the staff office. Chemicals were properly stored in a separate area and locked. The home is clean and in good repair. All the window screens are in good condition. Outdoor and indoor passageways were free from obstructions. Facility has first aid supplies. According to Ms. Chrisostomo, there were no firearms, ammunition, or other dangerous weapons in the facility. Discussed with the applicant continuing operation requirements, record keeping, reporting requirement and physical plant compliance.

The Pre-licensing and Component III was completed on today's date. Facility is ready for licensure pending management approval. This is a change of ownership application and there are four (4) clients currently in care. An exit interview was conducted with the Administrator, Chisostomo, and a copy of this report and Licensee/Appeals Rights were left with the Licensee, whose signature on this form confirm receipt of these documents.