Facility Evaluation Report

On 12/7/2023 at 10:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Lorna Hayag and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, shed, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 8/25/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 111.7 degrees F in the kitchen sink. There were adequate lights in each room. First Aid kit is complete. Last fire drill was conducted on 11/28/2023.

LPA reviewed 5 client and 5 staff files starting at 12:10PM. LPA interviewed 2 residents and 2 staff at 1:45PM. LPA reviewed a sample of resident's medications starting at 4:00PM.

At 11:21AM, LPA observed unlocked medications in the kitchen drawer. Staff locked up the medications during inspection.

At 11:25AM, LPA was informed by administrator that other clients have used the bathroom in C1 & C2's room.

At 11:35AM, LPA observed the shed in the backyard has a bed and was informed by administrator/staff that staff sometimes sleep/rest in the shed.