Facility Evaluation Report

On 7/5/2023 at 12:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with staff, Marlo Legarda. Administrator, Marissa Legarda arrived an hour later. The facility’s fire clearance was approved for 4 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 5/2/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 117.6 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathroom. There were adequate lights in each room. First Aid kit is complete. No bodies of water observed. Indoor and outdoor passageways were free of obstruction.

LPA reviewed 4 client and 3 staff files starting at 1:30PM. LPA reviewed a sample of client's medications starting at 2:50PM. LPA interviewed 2 clients and 2 staff starting at 3:45PM.

At 2:20PM, LPA observed clients does not have current needs and service plans on file.

At 2:30PM, LPA observed clients does not have functional capability assessment on file.