Facility Evaluation Report

At approximately 9:15 AM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced Annual Required inspection to this facility and met with Emilia Beralde, Administrator. At approximately 9:30 AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed debris and toxins in the backyard (motor oil, paint can, and paint chemicals. Administrator secured during visit. LPA advised Administrator to remove (wood and bed frame located near backyard gate closest to clients rooms) and secure toxic chemicals so they are not accessible to clients. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. LPA observed decayed (celery was discolored ranging from whitish light green to brown)and expired food items (container of food item expired on 05/02/2024), freezer items were not properly packaged and stored in the freezer and showed signs of freezer burn ( food was covered in approximately 1 inch of ice in folding sandwich bag that did not offer ziploc closure). Toxins inside the facility are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. LPA observed mattresses, Administrator advised client's sheets are changed once every 4 weeks. LPA advised Administrator clients sheets must be changed within a reasonable time and more than 1 time a month. Per Administrator she changes her own sheets 1 time a week. LPA advised Administrator, suggested client's sheets to be changed weekly especially with new client admission whom experiences incontinence . Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Two of two faucets accessible to clients measured between 114.3 and 116.3 degrees F, Two of two Fire extinguishers inspected were charged. Four out of four Smoke detectors and were tested and found to be in working order. Carbon Monoxide detector was present and in working order. Facility temperature was within regulation between 73 and 74 degrees F. Disaster Drills are conducted monthly with the last drill conducted 1/8/2024.