Facility Evaluation Report

Licensing Program Analyst (LPA) Miller arrived at 10:30 am and made an unannounced 1-year required annual visit to the facility above. LPA met with Jonelyn San Antonio, back-up administrator and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants sprays and cleaners. The facility has a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE).

Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on 12/12/23. Trash cans and wastebaskets have tight fitting covers. The facility has 4 client bedrooms and 2 bathrooms currently occupying 5 residents. The facility has smoke and carbon monoxide detectors that were tested. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 4 non-Ambulatory. A hospice waiver is approved for 2 residents. The facility currently has 4 ambulatory and 1 non-Ambulatory resident.