Facility Evaluation Report

Attempted visit was made on 12/14/2023 at 9:40AM, by Licensing Program Analyst (LPA) G. Luk.

On 12/21/2023 at 8:50AM, Licensing Program Analysts (LPAs) G. Luk and T. Syess-Gibson arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with Program Administrator, Ken Manu and explained the purpose of the visit. Program Director, Jessica Turner arrived 3 hours later. The facility’s fire clearance was approved for 6 ambulatory clients.

LPAs 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 7/7/2023. One week of nonperishable and 2-day of perishable food supplies were available. 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.

LPAs reviewed 3 client and 3 staff files starting at 9:30AM. LPAs reviewed a sample of client's medications starting at 11:30AM. LPAs interviewed 2 clients and 2 staff starting at 1:00PM.

At 9:15AM, LPAs observed unlocked cleaning supplies under the kitchen sink. Staff locked up the cleaning supplies during inspection.

At 9:30AM, LPAs measured hot water temperature at 133.9 degrees F in the hallway bathroom. Staff lowered hot water temperature and LPAs remeasured hot water at 108.2 degrees F during inspection.

At 10:36AM, LPAs observed unlocked medications in the refrigerator. Staff locked the lockbox during inspection.