Facility Evaluation Report

Licensing Program Analysts (LPAs) Daniel Konishi and Gabriela Castro conducted the unannounced Annual Inspection visit using the Compliance And Regulatory Enforcement (CARE) Tool. LPA met with S2 and the purpose of the visit was discussed.

The following 3 (CARE) tool domains were observed and reviewed: Personnel Records-Training, Client Records/Incident Reports, Incidental Medical Services.

Personnel Records-Training: Personal records centrally stored. However, LPAs were unable to review five (5) staff files since the staff files were locked and unable to open from admin and staff on the day of the visit. The valid administrator’s certificate was not provided to the LPAs. LPAs observed that the Admin, Staff #1 (S1) to Staff #4 (S4's) file did not have personnel records, documentation of background clearance, health screening, TB test results, valid first aid, and staff training in file. Administrator’s required HIV & TB training was not provided to the LPAs.

Client Records/Incident Reports: Client files are centrally stored. LPA reviewed four (4) client files. Client files have required documents. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Face sheet, Emergency and Identification Information form, Physician's Report (including T.B and Ambulatory Status), Individual Program Plan (IPP), Clients Personal Rights. However, LPAs observed in record review that Client #1 (C1's) medical assessment physician's report is missing physician's signature and date. Based on record review, LPAs observed that Client #3 (C3's) file is missing an updated physician's report last report dated 12/16/2022.