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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with Hazel Natividad, caregiver. Administrator Annedreah Santiago was contacted and arrived around 11:30 am. There was (1) client present at the start of the inspection in their room. (2) clients were attending day program and (1) client has been an outside rehabilitation facility since 1/17/25. The fire clearance is approved for (3) ambulatory clients and (1) non-ambulatory client. All clients are ambulatory.
LPA and the care staff toured the interior/exterior of the facility including the common areas, (4) client bedrooms, (2) bathrooms, kitchen, laundry, and garage area. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout and all client bedrooms are fully furnished. There are locks on each resident room door and auditory alerts on all exit doors. Clients keep the key when they are on site and ask staff to keep it when off-site. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food. The inside temperature measured 70*F, and the hot water temperature measured 116*F in the kitchen. Sharps, toxins and medications are locked in the kitchen and additional toxins are locked in the laundry area. The fire extinguisher was last serviced 7/10/24, and the smoke/monoxide alarms are working. The fire place is screened. There is a complete First Aid Kit. There is (1) unlocked exit gate and covered patio seating. Required postings are visible in the common area , including the facility sketch, Personal Rights, and activity calendar. LPA obtained updated cell-land phone.
LPA reviewed (2) client files. Files were organized and contained current documentation. P&I was checked for (1) client. Funds match ledger documentation. Surety bond exp Oct 2025. Medications were reviewed for (1) client. Orders/medications match documentation. (8) staff files were reviewed. All staff are cleared/associated and have completed initial training. Administrator showed LPA staff orientation training. Adult Residential Facility Administrator # 6052700735- exp 7/2/25.
There were no deficiencies observed. Exit interview. Copy of report provided to the Administrator. |