Facility Evaluation Report

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility by Staff, Mae Ramos. LPA spoke with Licensee, Chris Santos via telephone while at the facility.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, all of whom must be ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by licensee’s staff, 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. The facility’s ambient internal temperature was 75 degrees F. Hot water temperature at taps accessible to clients measured at 110 F. The refrigerator temperature was 45 F and freezer temperature was 0 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's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit(s) were 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 did not contain required documents. Confidential records were stored in locked areas. The licensee was issued a Technical Advisory on 11/28/23 regarding staff training. As of today, that training has not been completed/documented. In addition, there was no staff training on file for restricted heath care conditions, regarding inhalation devices that are used in the facility. The licensee was also made aware the facility's Plan of Operation needs to reflect all Restricted Health Care Conditions being provided in the facility.

A deficiency was observed and cited during today's annual inspection. Also, an Advisory Note was issued. An exit interview was conducted with Staff, Mae Ramos, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.