Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the Compliance and Regulatory Enforcement (CARE) tool. LPA arrived unannounced and met with Staff, Pat Lofton. The facility is licensed for (4) adults, ages 18 - 59, ambulatory only.

LPA toured the facility, reviewed files, and conducted interviews with 2 staff and 3 clients. The following were observed:

The facility does not have any pools or bodies of water on the premises. There are 3 client bedrooms, 2 bathrooms, living room, t.v. room, kitchen, laundry area, and detached garage. The client bedrooms have the appropriate furniture and storage space. Facility has an operable smoke detector in each room and a carbon monoxide detector located in the living room. Knives and cleaning solutions are locked. The hot water temperature is measured by staff and logged daily. The facility is operating within the fire clearance approval. Staff are providing care and supervision to meet the clients' needs and assisting in activities of daily living. Staff are continuing to follow their infection control plan and procedures while handling clients.

LPA observed sufficient food supplies of 2 day perishable and a week of non-perishable items. Foods are properly stored in the refrigerator to avoid contamination. There appears to be sufficient staffing to assist the clients. Staff are fingerprint cleared and associated to the facility. LPA reviewed 3 personnel files. The administrator's certificate expires on 12/2/24 and the HIV & TB certificate was issued on 9/6/23. Staff have current CPR & First Aid training. Staff do not use any manual restraints on clients. LPA also reviewed 4 client files and their medications. Medications are centrally stored in the metal cabinet and are being administered as prescribed. The client files contain the admission agreement, Emergency and Identification form, consent forms, medical assessment with TB test results, Personal Property and Valuable form, and personal rights form. The facility has the updated emergency and disaster plan. Disaster drills are conducted monthly.

No deficiencies were observed today. An exit interview was held and a copy of this report was given to staff.