Facility Evaluation Report

On 1/25/2024 at 1:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Jacqueline Santos and explained the purpose of the visit. The facility’s fire clearance was approved for 6 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, shed, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 2/2/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 109.4 degrees F in the hallway bathroom sink. There were adequate lights in each room. First Aid kit is complete. Last fire drill was conducted on 1/26/2024.

LPA reviewed 3 client and 3 staff files starting at 2:30PM. LPA reviewed a sample of client's medications starting at 4:25PM. LPA interviewed 2 clients and 2 staff at 4:40PM.

At 2:00PM, LPA observed the shed in the backyard has a bed and was informed by administrator that S2 has been sleeping in the shed.

At 3:00PM, LPA observed C1 and C3 does not have current appraisals on file.

At 3:10PM, LPA observed all clients does not have functional capability assessment completed.