Facility Evaluation Report

On 07/09/25 Licensing Program Analyst (LPA Javina George conducted an unannounced annual required visit. LPA was granted entry by Caregiver Maria Rivera, where LPA informed of the purpose of the visit. Both the facility manager Maria Shriver and Administrator William Lewis arrived during the visit. At the time of the visit there was two (3) staff and one (1) client present, during LPAs visit. Four (4) clients were at the day program, and (1) is out at a Skilled Nursing Facility. The facility is licensed to serve age 18 through 59, approved for five (5) non ambulatory and (1) bedridden resident. In addition, the facility has an approved hospice waiver for (2). There are currently zero (0) clients receiving hospice services or bedridden.

The facility was observed to be clean and furniture was in good repair. The sharp and dangerous objects, chemicals and other hazardous items were observed to be locked and inaccessible to clients in care. The medications are locked in a medication cart, and the facility is using an electronic MAR software program. During the inspection of the facility interior LPA initially observed (2) of the combined smoke detector and carbon monoxide to not be operable as the batteries were pulled out in (2) different client bedrooms. A battery was pushed in and continuous beeping began. The administrator changed the battery before the conclusion of LPAs visit. However, the citation and civil penalties are still being issued due to it being evident/known that the batteries needed to be replaced, and there is zero tolerance for inoperable detectors. The emergency disaster drills are being conducted on a quarterly basis with the last drill being conducted on 06/10/25. The hot water temperature measured to be 105 degrees Fahrenheit. The facility food supply was sufficient as there was a 2-day supply of perishable and 7-day supply of non-perishable food items. Staff present were observed to have obtained criminal record clearance and to be associated to the facility. The CPR/First Aid Certification was observed to be valid with an expiration date of today 07/09/25. Staff were enrolled in CPR training during LPAs visit, and certificates will be provided to the department upon