Facility Evaluation Report

Licensing Program Analyst (LPA), Jacqueline Shaw Ross conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA Shaw Ross met with Executive Director, Miriam Silva and explained the nature of the visit and was granted entry into the facility. The facility was inspected inside and out. At the time of the visit, three staff and six clients were noted to be present.

The facility is one story with four bedrooms and two bathrooms. Two of the bedrooms are shared with two clients in each bedroom. The other two clients have their own bedrooms. Client bedrooms were observed to be clean and appropriately furnished. The facility appears clean and free of odors. Food supplies are sufficient. LPA Shaw Ross observed all toxic chemicals and other hazards secured and inaccessible to clients. Hot water was tested and deemed safe at 123.9 degrees. All smoke and carbon monoxide detectors were tested and found operable. Medications are centrally stored in a locked cabinet in the kitchen. P&I funds are stored in a safe in the staff office and are maintained separately from facility funds. Furniture in the facility is in good repair. Outdoor space is free of hazards.

LPA Shaw Rossinspected the staff and client records. Staff present have criminal record clearances and are appropriately associated to the facility. Staff files had the required documentation including First Aid Certifications and training documents. LPA confirmed the administrator paid and requested for a new administrator's certificate. Client records were reviewed and IPPs were observed to be up to date. LPA inspected medications and medications appear to be dispensed appropriately according to the physician's orders. The facility is completing emergency drills as needed. Staff and client interviews were conducted.

During the inspection, no deficiencies were observed.

An exit interview was conducted and a copy of the report and LIC 811 was provided to the Executive Administrator, Miriam Silva.