Facility Evaluation Report

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Trueman met with Facility Manager Gia Williams and explained the purpose for the visit.

The facility is licensed to serve (5) developmentally disabled adults ages 18-59 years old, all ambulatory. Facility is operating within the approved capacity. Currently, there are four (4) clients in placement, there are no clients who have a restricted health care condition. All clients residing at this facility receive case management services provided by South Central Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention.

During the visit LPA observed the following:

Interviews were conducted with the 2 staff on duty and 4 clients were interviewed.

4 client files were reviewed and 5 staff files were reviewed. All staff were cleared and associated.

Medication was administered per physician's directions.

Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.

Licensee maintained an individual admission agreement for each client.

Fire Clearance has been maintained. Water temperature measured 105 F.

Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations.

Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.

There is an adequate number of direct care staff to support each resident's physical, social, emotional safety and health care needs as identified in his/her current appraisal.