According to the facility’s license, the facility has a maximum capacity of four (4) clients; two (2) ambulatory and two (2) non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients measured at 105 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit needed gauze and a current First Aid Manual. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and client files. The reviewed files did not contain required documents. Staff's First Aid expired January 2025, disaster drills are not conducted, the last fire drill was on 05/18/23, a client has a helmet but no exception on file, Centrally Stored Medication Destruction Record is not being completed, Annual disaster training not conducted, last disaster training was 01/19/22, clients physician orders on file for medications but not signed by physician, the IPP and/or Needs and Service Plans are more than one year old, and a client needs an updated physician's report to reflect correct ambulatory status. Confidential records were stored in locked areas. The facility has a camera installed in the common area. Per staff, the camera is inoperable and not connected.

Deficiencies were observed and cited during today's annual inspection. Along with Technical Advisories. An exit interview was conducted with Staff, Charito Llanos, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.