Facility Evaluation Report

During a Complaint visit on the date & times indicated above, Licensing Program Analyst (LPA) K. Mcclurg observed & reviewed the following violations with Consulting House Manager (CHM) Phoeun Marez.

Magnetic key to open drawer in kitchen containing medications observed to be accessible on metal light switch opposite drawer. Key accessibility makes medication in locked drawer accessible posing an immediate risk to residents. Key was made inaccessible at time of visit.

Staff currently working 24 hour days. Vacant resident room #1 currently being used a staff room. Rooms may not be used for any other purposes other than as designated as licensed. Room is designated as a resident room, not for use as a staff room.

Have awake staff @ all times, including overnight,

Request to change facility's license to designate a dedicated staff bedroom.

Licensee would need to request change of capacity to decrease capacity from 6 to 5.

If want to retain license for 6 residents, room #1 will require fire clearance for 2 residents. Initially inspected only for 1 per licensee request @ time of application.

Please submit a Letter of Intent of how issue will be addressed by due date of Plan of Correction (POC).

If adding a staff room for the time being, please indicate if would like to decrease capacity to 5 or would like to have fire clearance for 2 non-ambulatory/bedridden residents in room #1.

Please follow through wit h the Department to initiate desired changes by due date of (POC).