Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA met with Assistant Administrator, Jose Alderete, who assisted with the inspection. The annual inspection was first initiated on 7/6/23. LPA continued with the remaining domains listed below today.

Staffing : There is sufficient staffing at the facility. There is an awake staff for the overnight shift. The Administrator's certificate for Travis Holland expires on 7/31/23. Staff are fingerprint cleared and associated to the facility.

Personnel Records-Training : LPA reviewed 3 staff files. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff have 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 all 3 Client files. The files include the Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent For Medical Treatment, Individual Program Plan/IPP, Client Rights, and Property Valuable forms.

Health Related Services: The medications are centrally stored and locked. LPA reviewed medication for all 3 Clients. Staff documents on the Medication Administration Record (MAR) log when given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: There are no clients with a restricted health condition plan.

Disaster Preparedness: The facility has the Emergency Disaster Plan with emergency procedures noted.

There are no deficiencies issued today. A technical assistance was provided. An exit interview was held and a copy of this report was given to Jose Alderete.