Facility Evaluation Report

On 01/10/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual

inspection. LPA introduced self, stated the purpose of the visit and met with Administrator Maryann Hagstrom. LPA completed a tour of the facility with Administrator. Clients were observed in the activity rooms and walking around kitchen.

The facility is maintained at a comfortable temperature and no passageway obstructions or fire hazards were observed. Transportation is available and provided for clients. LPA and Administrator observed cleaning chemical unlock under back bathroom sink and bug spray unlock in the transportation room. Kitchen was toured. Kitchen was toured and observed refrigerator at 40 degrees F. Clients bring their own lunch and snacks to the program. LPA and Administrator observed chemicals under kitchen sink unlock.

LPA observed medications locked in the facility medication room. MARs were reviewed. LPA observed clients’ personal basket in the front entrance. Client bathrooms were tour, observed to be clean, and operational. Hot water temperature was 110.8 degrees F in bathroom 1, 111.1 degrees F in bathroom 2, and 106 degrees F in the back bathroom. Fire extinguishers throughout the facility was observed with served date: 10/25/23. Last fire drill completed on 10/25/23. Chemicals and cleaning supplies were observed locked in the facility laundry room and soda closet. Outside was observed clear of debris. A sample of client files were also reviewed and observed one out of three clients did not have all the required documents. A sample of staff files were reviewed and observed to have all the required documents.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit Interview conducted. The following documents are requested and to be submitted to Fresno CCL by: 01/16/24. The following updated forms were requested: Lic 308, and Lic 610D. A copy of this report and appeal rights was provided to the Administrator, whose signature confirms receipt of this report.