Facility Evaluation Report

Licensing Program Analyst (LPA) Christian Gutierrez conducted an annual continuation visit. Upon arriving at the facility, LPA met with staff Ronald Brown who assisted with the visit.

On 01/06/2025 LPA conducted an initial visit. During today's visit LPA Gutierrez reviewed the following CARE inspection tool domains: Infection Control, Staffing, Personnel Records/Staff Training, client rights, client records, health-related services, incidental medical services, disaster preparedness, and emergency intervention.

Four (4) staff files were reviewed and included criminal clearance record, and health screening with TB. Four staff were missing CPR/ First Aid deficiency cited. Six (6) Client files were reviewed and included physicians reports and appraisal needs and service plan. C1 was missing Physicians report with TB and C2 was missing admission agreement. No Fire/earthquake drill was ready for review at time of visit. Infectious control plan and emergency disaster plan was not available at time of visit. The medications are centrally stored and locked in a cabinet in hallway. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.