Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Tyrone "Aaron" Powell. Co-Administrator Maria DeGuzman arrived during the visit.

The facility has a licensed capacity of 6 ambulatory clients. During today’s visit, the facility had a census of 6 ambulatory clients. The Administrator for the facility is Tyrone Powell and their certificate was valid and current.

During today’s visit, LPA inspected each room of the facility, including client and staff rooms, common bathrooms, kitchen, garage, common areas, and outside space. No bodies of water, delayed egress, or secured perimeter were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. LPA observed linens and hygiene products for client use. The facility’s ambient and water temperature were measured within regulatory requirements at multiple locations. LPA observed locked storage for client medications which were stored separately from food supplies. LPA observed knives and sharp items which were located in unsecured drawers and in the kitchen sink and observed staff medications in the staff bedroom, which was unlocked. LPA observed staff relocate sharps to locked storage and locked the staff bedroom. According to Aaron Powell, no firearms or weapons are stored on the premises. LPA observed a minimum supply of 2-days of perishable food and 7-days of non-perishable food. The refrigerator and freezer temperatures were kept within requirements.