Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to complete the annual inspection. LPA arrived unannounced and met with Administrator, Brittany Jones. The purpose of the visit was explained.

LPA continue the inspection using the CARE tools:

Staffing : There is sufficient staffing at the facility. Administrator Certificate for Brittany Jones expires on 8/1/24. The HIV and TB Training was completed on 4/22/22. Staff employed are fingerprint cleared and associated to the facility.

Personnel Records-Training : Staff files are maintained at the facility. LPA reviewed 3 staff files. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis result on file. Staff are receiving on-going training.

Client Rights-Information: Client rights are posted and included in Client files. There are no clients using postural supports.

Client Records-Incident Reports: LPA reviewed all 4 Client files. Client files are organized and include the following documents: Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent For Medical Treatment, Individual Program Plan/IPP, Client Rights, Inventory form, and P&I ledgers.

Health Related Services: The medications are centrally stored. LPA reviewed medications for 2 Clients who are taking medications. Facility uses the Medication Administration Record (MAR) log to document medications given and are being administered as prescribed by the Physician.

Incidental Medical Services: There are (0) clients with restricted health condition plan.

No deficiencies were issued. An exit interview held. A copy of this report was given to the administrator.