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 Administrator Justin Felan. LPA discussed the purpose of the visit with Administrator Felan.

According to the facility’s license, there may be a maximum of six (6) clients all of whom may be ambulatory in at any given time at the facility site; and staff shall be awake at all times. During today’s inspection, the facility’s current census is 4 client’s living at the facility. There were two (2) client’s present at the facility site, but left during the inspection. Upon one client's return the client went to rest.

LPA, accompanied by Administrator Felan, 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. 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.

The facility’s ambient internal temperature was comfortable and compliant, at 71 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink measured at 117 degrees F; sink in restroom #1 delivered hot water at 115 degrees F; sink in restroom #2 delivered hot water at 111.6 degrees F; and laundry room delivered hot water at 112.3 degrees F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to clients. LPA inspected and found that medications were properly labeled, as required, and stored in a locked cabinet. The facility maintained medication system which LPA reviewed.