Facility Evaluation Report

LIcensing Program Analyst(s) (LPA) Ashley Calderon conducted a case management annual continuation visit at the above facility with focus on using the CARE Inspection Tool. LPA Calderon met with DSP staff #2 (S2) and explained the reason for the visit. Administrator Cheryl Jackson arrived at 10:15AM.

On today's visit, LPA interviewed a total of (3) staff , (2) clients and attempted (2) client interviews.

LPA observed alongside with Cheryl Jackson/ Administrator, facility refrigerator and freezer, having no thermometer in place. LPA interviewed Administrator and Staff #2 who confirmed no thermometers in place in the freezer and refrigerator, deficiency cited.

LPA continued questions on CARE tools to complete annual inspection. LPA reviewed training's, (5) client files and (4) staff files. During LPA record review for clients file review, Client #8 (C8) did not have admission agreement in place, LPA observed record of client#8 (C8) and had Administrator assist to locate admission agreement, admission agreement was not placed in file, deficiencies cited.

LPA reviewed medication and medication records for (3) clients in care, no deficiencies noted.

Deficiencies were noted per Title 22 Regulations. Exit interview was conducted with Administrator Cheryl Jackson and a copy of this report, LIC 809D, and appeal rights were provided via email to Administrator due to LPA's printer issues.