Facility Evaluation Report

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Program Director Flor Angel Real where LPA explained the purpose of the visit. At the time of LPAs visit there was (48) clients and (28) staff. The ratio is 3:1. LPA observed for all staff to have obtained criminal record clearance and to be associated to the facility. Below are the observations made from today's visit:

LPA conducted a tour of the interior and exterior of the facility. The facility is a single level suite consisting of a music room, art room, (4) personal care rooms, nurse's office, kitchen and (4) activity rooms. There are 2 bathrooms for the clients to use, the clients bring their lunches from home, and the program provides snack that is followed by a weekly schedule. The facility mitigation plan is on file dated 1/22/21.

The smoke and carbon monoxide detectors were tested by a local contractor and all parts connected to the detectors were operable and found to be in good repair. The emergency disaster drills are being conducted on a monthly basis, and the last drill conducted was on 4/30/24. The fire extinguishers are fully charged and were recently inspected on 4/19/24. There are no known guns or ammunition on the premises. The medications are locked inside a medication cart that is stored inside the Nurse's office. There are no pools or bodies of water on the premises. The sharps are locked in a cabinet in the kitchen underneath the sink. The scissors or shears are stored in a locked drawer below the counter where the microwave oven sits. The hot water was tested and measured at 108.8 degrees F.

The facility was observed to have the required postings such as emergency disaster plan, personal rights, license, facility sketch and CCL complaint poster (PUB475). The chemicals are stored a locked cabinet underneath the kitchen sink as well as in a locked closet, inside the big room by the supervisor's office.

Both client and staff files were reviewed and the facility uses an electronic program called Therap.