Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to complete the remainder of the annual inspection. LPA arrived unannounced and was allowed entry by staff, Ricardo DeClaro. Administrator, Mona Dela Rosa arrived shortly thereafter to assist with the visit.

During the visit today, LPA finished the following domains using the CARE tools.

Staffing : There is sufficient staffing at the facility. Administrator Certificate for Mona DelaRosa expires on 2/22/24 and the HIV and TB Training certificate was completed on 1/27/22. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training : Staff files are maintained at the facility. LPA reviewed files for 4 Staff. Staff files have current First Aid/CPR certification, Health Screening and Tuberculosis Screening on file. Staff are receiving on-going training.

Client Rights-Information: Client rights are posted and included in Client files. There are no clients using postural supports.

Client Records-Incident Reports: LPA reviewed files for 4 Clients. Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent Forms, Individual Program Plan/IPP, and Client Rights were observed.

Incidental Medical Services: No clients have a prohibited health condition. There is 1 client with a restricted health condition plan.

Disaster Preparedness: The facility has the updated Emergency Disaster Plan (LIC610D) in place.

Emergency Intervention: All Staff have CPI training. Staff will utilize mainly redirection.

No deficiencies issued today. Exit interview, appeals rights and a copy of this report was provided to the Administrator.