Facility Evaluation Report

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by maintenance personnel, Thomas Arlington. LPA discussed the purpose of the visit with staff Arlington. A few minutes later, Licensee arrived and joined the visit.

According to the facility’s license, there may be a maximum of four (4) clients all of whom may be non-ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is 4 clients living at the facility. All clients arrived from their respective programs during the licensing inspection. LPA was able to speak with clients and reviewed clients and staff records. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

LPA, accompanied by Licensee Engle, toured the interior and exterior parts of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities.