Facility Evaluation Report

Licensing Program Analyst (LPA) Javina George conducted a joint health and safety check with the placing agency, Service Coordinator Bianca Landgrave. At the time of the visit was one (1) staff and (0) resident's present as the residents were at the day program.

During today's health and safety check LPA observed for the facility to have expired food, consisting of (3) loaves of bread, 2 bags of shredded cheese, bottle of sweet and sour sauce, and (3) bags of frozen meals. The items were discarded during LPAs visit. However due to this being a repeat observation with the last incident occurring on 2/28/24. Deficiency cited.

The facility was observed to have working utilities (gas, water, electricity). The medications are locked and inaccessible to the residents in care. The facility has a supply of hygiene products such as soap and shampoo for the residents to use.

Regarding the observations made in the resident bathroom during the visit conducted on 3/29/24. LPA observed for the linoleum that was lifting around the toilet seat to be taped to the ground. Per Administrator Manuel he will be trying a glue instead of tape. LPA observed for the paint on the cabinet inside the bathroom to be intact as it was taped down with clear tape preventing residents from being able to pick at the paint. LPA conducted a review of the facility personnel roster, as there have been some staffing changes.

The following was discussed during today's visit with the Administrator:

-Associating S1 to the facility by 5pm today 4/18/24

-Cleaning the window sills to remove the dust and cobwebs that were observed

-Having a copy of the program design available at the facility to review

-Follow up regarding medications that are needed for the residents at the day program

-Enroll in an upcoming Home and Community Based Services (HCBS) Final Rule training