Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 8/16/24. LPA arrived unannounced and met with Staff, Jamila Rahmaan. The facility is licensed for (4) adults, ages 18 - 59, and can be non-ambulatory.

LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tools and observed the following:

The facility does not have any pools or bodies of water on the premises. There are 4 client bedrooms, 1 administrator's room, 1 staff room, 3 bathrooms, living room, dining area, kitchen, and an attached garage. 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 in the staff office. 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. There is an extra refrigerator in the garage. The food is properly stored in the refrigerators.

There are 3 ambulatory clients residing at the facility. LPA reviewed 3 client files. 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. LPA also reviewed 3 Staff 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. Medications are centrally stored in the staff room and are being administered as prescribed. 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.