Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and followed up on SOC341 along with an incident report. Program Manager, Diana Mendez greeted LPA. Required postings were observed. Annual fees are current.

LPA/staff initiated tour of the facility and observed the following: Facility has a large open/pocket area for participant's activities, changing rooms, administrative offices, quiet room, three bathrooms, kitchen and dining area. Toxins are stored in various locked closets/storage rooms. One locked storage room containing cleaning supplies near the washer and dryer. Medications are centrally stored in the nurses office. A refrigerator is located in the kitchen to accommodate client lunches and snacks. Water temperature in bathroom read at 108.7 and 110.7 which is within regulation of 105 and 120 degrees F. Clients were participating in variety of activities at the time of visit.

Fire extinguishers are fully charged and were last serviced January 2024. Sprinklers and pull stations are located throughout the facility and are tested regularly by a vendor who contracts with the landlord. First aid kits were observed. Carbon monoxide detectors were present and working at the time of visit. Program does not provides transportation. Medications & records were reviewed. One Licensed Vocational Nurse (LVN) is at the facility whenever clients are present to support clients with restricted health care needs. Per Administrator, the facility is not accepting individuals into the program until they have an additional LVN to safely support the participants in care and NBRC has placed them on the no referral list.