Facility Evaluation Report

Licensing Program Analysts (LPA) Liliana Silveira conducted an unannounced visit to continue a required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Assistant Director Cassidy Pacheco. LPA also spoke to Director Priscilla Grossman.

According to the facility’s license, the facility has a maximum capacity of 14 clients, ages 18-49 years, five of whom may be non-ambulatory. Facility is also approved for insulin dependent diabetics. During today’s inspection, there were a total of 11 clients in care, and per medical records, all were ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Priscilla also presented proof of current/active business liability insurance.

No pools or bodies of water were observed on the premises. Per Director Priscilla Grossman, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

LPA, accompanied by Priscilla, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. (continued on next page, LIC 809-C)