Facility Evaluation Report

Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee/Administrator Belinda Miguel. Clients were present at the facility during this visit. Facility has 1 client who works and 6 clients in day programs.

LPA arrived at the facility and logged into visitor/client’s binder. During facility tour on 11/16/2021 with licensee/administrator Belinda Miguel; facility was found to be at a comfortable temperature with all exits free from obstruction. A sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 01/2021 at the time of the visit. Sample inspection of Smoke & Carbon monoxide detector was found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked laundry room in the first floor. However, there were 2 out of 3 bathrooms which LPA observed (bathroom number #3 and #2) toxins that were accessible to clients. (see pictures, LIC 809-D) Facility hot water temperature measure between 132.2 degrees F & 133.3 degrees F falling out of Title 22 acceptable regulations of 105 to 120 degrees F in 3 out of 3 clients’ bathroom faucets. (see LIC 809-D) In addition, LPA observed during this visit that showers and bathrooms were not sanitary and a number of debris in the backyard. (see pictures, LIC 809-D) Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Sample client’s bedrooms have appropriated lighting.

Facility has submitted a mitigation program plan that has been review and approved at this time. Posters have been placed at entrance and small table with sign-in sheet for visitors and clients. Staff before coming into work has temperature checked. Facility has some PPE supply stored in the staff room. Facility has hired new staff and admitted clients since COVID-19. Clients’ medications are stored and locked in a closet inside staff room. Facility has a 30-day supply of medication for clients.