Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Director of Compliance (DOC) Cecilia Steinbach.

The facility has a licensed capacity of 6 ambulatory clients. During today’s visit, the facility had a census of 1 ambulatory client, who was not present during the visit. The Administrator for the facility is Cecilia Steinbach and their certificate was valid and current. During today’s visit, LPA inspected each room of the facility, including client rooms, private and 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 and hazardous and/or toxic chemicals, both of which were stored separately from food supplies. According to Cecilia Steinbach, 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. Staff present at the facility had a criminal background clearance and association. LPA reviewed client and staff records. Review of Client 1's (C1's) medical assessment revealed that the facility did not have the results of C1's tuberculosis prior to C1's admission to the facility.

The following deficiency was cited for tuberculosis testing and noted on the attached LIC809-D page. An exit interview was conducted with DOC Cecilia Steinbach, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).