Facility Evaluation Report

Licensing Program Analysts (LPA) Marcela Yanez and Licensing Program Manager April Cowan conducted an unannounced visit and met with Administrator (ADM) Melissa Ramos LPA announced the purpose of the visit. LPAs observed 62 Clients and 31 Staff.

LPA toured the facility inside and out with ADM which included the main activity area and music room, kitchen, dining room, restrooms. The staff area of the facility was also inspected. The outside of the facility was also inspected. There was no obstruction to block the walkways. LPA observed 12 Vans that take Clients to community outings and to and from home. ADM stated vans are serviced for scheduled maintenance and as needed.

During the visit, LPAs observed clients doing marching around the room to music in the main activity area. During tour LPAs observed cubby holes where the Clients place their personal items.

LPAs observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured with thermometer 118-119 degrees F in both the men's and women's restroom. LPAs observed paper towels and soap and covered trash cans.

There were 3 fire extinguishers observed in the facility and were last serviced in 08/30/24 LPAs observed a dual fire alarm system with carbon monoxide detectors which in all areas. ADM stated that the dual alarm system is maintained every year and last time it was serviced was on 09/2024. LPAs observed facility first aid kit.