Facility Evaluation Report

Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced annual visit using the CARE Tool. LPA met with Lead DSP/Assistant Administrator Lakeisha Trotter and explained the reason for the visit. Facility is licensed to serve 4 ambulatory only clients in the age range of 18 through 59.

A tour of the single-story facility included the 4 client bedrooms, 2 bathrooms, living room, dining area, kitchen, laundry room, front yard, backyard and attached garage. LPA observed the facility sketch posted in a broken frame near the front entrance. Assistant Administrator Trotter was unable to remove the frame. The frame has a crack in the glass stretching from the top corner of the frame to the bottom corner. LPA conducted the tour with Staff #1 (S1) and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps are kept in a lock box. LPA Reyes observed with S1 Cascade Platinum Plus Dishwater Detergent Pods underneath the kitchen sink in an unlocked cabinet and accessible to (2) clients. Detergent pods were observed with S1 inside the box. LPA observed S1 remove the detergent pods and centrally store and lock in a cabinet in laundry room.Client #1 (C1-C4) medication was reviewed with Assistant Administrator Trotter. Medications are documented properly and given as prescribed. LPA observed with S1 and Assistant Administrator C1’s medication Wegovy Auto Injection 1mg inside an unlocked fridge in the laundry room and accessible to clients. Inside the Wegovy Auto Injection box was (3) injections. LPA observed Assistant Administrator Trotter lock fridge with medication inside. LPA reviewed (4) client and (5) staff files. First Aid kit is locked in the medication cabinet, and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinets. Dining and living room have sufficient lighting and sitting area. All bedrooms have all required furniture, lighting, and bedding. All showers were observed with non-skid material. Last Emergency Disaster Drill conducted on 10/17/24 Earthquake and 10/25/24 Fire.