Facility Evaluation Report

At approximately 12:30PM, Licensing Program Analyst (LPA) Chris Arnhold conducted an unannounced Annual Required inspection to this facility and met with Kim Vargas. At approximately 12:45PM, LPA toured the building and grounds. LPA observed the bathtub in 1 of 2 client bathrooms was in need of repair. The areas around the tub showed water damage and mold. The remaining areas of the facility were found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Fire extinguishers inspected were charged. Smoke detectors were tested and found to be in working order. Carbon Monoxide detector was present. Disaster Drills are conducted monthly.

At approximately 1:30PM, LPA reviewed 4 of 4 Client records and 2 of 4 Staff records, which were all found to be well organized, thorough and contained the required documentation. First aid and CPR certification were current in staff files reviewed. P&I monies were documented, secure and not commingled.

During this inspection, LPA followed up on an incident report submitted by the facility on 03/13/2024. The incident was in regards to a staff giving a client a double dose of medication. Staff noticed immediately and made all the proper notifications. Staff attended additional training after the incident.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Kim Vargas and Appeal rights were given.