Facility Evaluation Report

Licensing Program Analyst (LPA) K. Kaur conducted an unannounced Annual inspection visit. LPA met with Program Director Jaenette Madkins and Area Director Hanh Mireles, and discussed the purpose of the visit.

LPA and the Program Director toured the facility together. Facility is maintained at a comfortable temperature. LPA observed adequate seating and lighting throughout the facility. No passageway obstructions or hazards were observed inside or outside. Client restrooms were toured, observed to be clean, and operational with adaptive devices. Facility dining area was toured. Clients bring their own lunches to program. Locked cubbies were observed in several areas. Cleaning supplies were observed behind locked door, in a storage room. LPA toured the rest area for quiet space. At 1:09 PM LPA observed Fire extinguishers was expired with a service date of 10/8/2023.

LPA observed clients in various rooms eating and participating in various activities; puzzles, games, watching favorite shows, and styling class. Staff were present in each activity room actively supervising and engaging with clients.

Client’s records contained signed Admission Agreement, Personal Rights, and TB clearance. LPA observed 4 out of 5 residents did not have medical assessments. Medical Progress notes were observed from examinations; however, did not have the required information. LPA observed 1 client had a IPP that was dated 2022. Staff files were reviewed for good health. It was verified that current staff on duty are CPR certified. Last Fire Drill conducted on 8/23/2024. During Medication review, LPA discovered a R1’s Medication count was short by 1 pill. Centrally Stored Medication Destruction Record (CSMDR) was marked with a start date of 10/1/2024. Per interview with Program Director 1 pill was given for the previous month.