Facility Evaluation Report

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit Licensee, Cesar Torres. The facility's license shows a maximum capacity of four (4) ambulatory clients.

LPA, accompanied by licensee, 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 and screens, 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 client activities. Hot water temperature at taps accessible to clients measured at 109 degrees F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and client records/files. The reviewed files contained required documents. However, Client #4 (C4) was missing an IPP/Needs and Service Plan. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection. An Advisory Note was issued for C4 not having an IPP/Needs and Service Plan. An exit interview was conducted with Staff, Melanie Torres, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. [See LIC 858 Client/Resident's Records Review to identify Client #4]