Facility Evaluation Report

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct the required annual licensing inspection. LPA was greeted by Licensee Andrade and identified herself, was granted entry into the facility, and stated the purpose of the visit.

The facility is licensed to serve three (3) ambulatory clients. During today’s visit one (1) client was present.

LPA conducted a review of facility, staff, and client records. Facility records, including but not limited to the Limited Liability Company (LLC), liability insurance, disaster and infection control plans, staff and client rosters, and surety bond were all present and active. The facility’s last disaster drill was on September 2, 2025. Staff records were observed to be complete and up to date including staff training, clearance, health screening, first aid/CPR certification, contact information, and hiring paperwork. Client records also contained all the required documents that were complete and up to date. Personal and Incidentals (P&I) and Client Medication Administration Records (MAR) were accurate and complete.

LPA, accompanied by Licensee Andrade, also conducted a facility tour. The facility temperature was 69 degrees Fahrenheit at the time of the visit. The client bathroom's hot water temperature measured with-in regulation requirements. Disinfectants, cleaning solutions, poisons, and sharp objects were inaccessible to clients in care. All client rooms were equipped with the required furnishings. Client bathrooms were observed to be sanitary and equipped with the required safety measures, including grab bar and nonskid flooring in the shower. LPA observed smoke alarms, and carbon monoxide detectors that were in operable condition. Fire extinguishers were present and current on inspections.