LPA Enriquez and LPM Coronel conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pe-Licensing Checklist and Component III Orientation.

MEDICATIONS

There is a locked centralized storage area for client medications.

Report continued on 809-C

Facility is clean, sanitary, and in good repair. Protective devices are in place to include nonskid material on rugs. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. There are NO pools and bodies of water on the premises. There is a locked storage area for poisons. NO firearms or weapons on the premises. All window screens are clean and in good repair. Facility temperature is 72 degrees. NO fireplaces and open-faced heaters on the premises. Stairways, inclines, ramps, open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. Fire Alarms and Smoke alarms operate properly. Carbon monoxide detectors operate properly.

BEDROOMS

Halls, storage, and detached garage areas are not being used as client bedrooms. Client bedrooms are large enough to allow for easy passage and to accommodate furniture. No client bedroom is a passageway to another room, bath, or toilet. There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) night stand per two (2) clients.

Continued on 809-C

There is at least one (1) toilet and washbasin per six (6) clients, family, and personnel. There is at least one (1) shower or bathtub for the six (6) clients, family, and personnel. Hot water temperature is between 118 degrees Fahrenheit. Bathroom is located near client bedrooms. There are nightlights in the hallways outside non-private bathrooms.

SUPPLIES

There are client personal hygiene supplies to include feminine napkins, soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE

Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0 degrees Fahrenheit. Refrigerator is a maximum of 45 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS

There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility.

Continued on 809-C

The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Postings of the Personal Rights meets regulation. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

ACTIVITIES

There is an outdoor activity space that is furnished with outdoor table, chairs and sun umbrella for shade. There is at least one common room with seating and TV available for clients and visitors. There are activity supplies to include board and card games, magazines and books

MISCELLANEOUS

There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is a designated laundry space and washer/dryer attached to the outside of the back of the home in a covered patio. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. Vehicle used to transport clients are in safe operating condition.

PRE-LICENSING CHECKLIST

Completed by licensee and reviewed by LPA Enriquez

COMPONENT III

LPA Enriquez presented the Component III Power Point training to applicant and discussed how to operate the facility within substantial compliance.

Continued on 809-C

1.LPA and LPM oberved that the facility only had four (4) beds; whereas the facility has been licensed and cleared for a capacity of six (6) residents. Administrator indicated that she would like to decrease her capacity to four (4) residents. LPA and LPM advised Administrator to contact CAU and submit a change to the licensing application requesting a decrease from six (6) residents to four (4). Adminstrator to provide LPA with updateds of application submission to CAU.

2.LPA and LPM observed that the facility had security cameras in the exterior of the facility and interior common areas. Cameras were observed as non-operational at the time of the visit. Administrator to have cameras operational by correction date and submit proof to LPA.

An exit interview was conducted, and a hard copy of this report has been furnished to the applicant.

Accordingly, LPA Enriquez will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to the applicant.