Facility Evaluation Report

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Direct Support Staff (DSP) Gabriela Hernandez who was informed of the purpose of the visit. Licensee Leena Dost arrived shortly after LPA's arrival. At the time of the visit there was two (2) staff and zero (0) clients present. The clients served are ambulatory adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. The outdoor area was observed to be free of hazards. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Two (2) client files were reviewed and contained all required paperwork including Admissions Agreement, Updated Physician's Report, and Individual Program Plan (IPP). LPA inspected the P&I for two (2) clients and found no discrepancies. All client medication was locked in a cabinet located in the staff office. LPA reviewed client medications and found all medication listed on the Medication Administration Record (MAR) were present and all required labeling and signatures was found to be in place. LPA reviewed the facility's emergency and disaster plan. Facility conducted their last fire drill on 07/31/2024 which met the department requirements. LPA observed emergency supplies in the garage, first aid kit with all required items, and one (1) fire extinguisher located near the kitchen with a inspection date 05/16/2024. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate. No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Licensee Dost