Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Ademola Salau, Administrator, Josanne Lambert/Direct Support Professional (DSP) and Divette Bias/Program Supervisor and explained the purpose of the visit. The facility is licensed to care for Developmentally Disabled Adults, ages 18 through 59, (4) ambulatory, of which (2) may be non ambulatory. All clients residing at this facility receive case management services provided by Harbor Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility does have COVID-19 signage still posted in the facility. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Surety Bond Insurance (Atlantic Specialty Insurance Company) is valid and in effect. Fire Drill was conducted on 5/22/2023 and Earthquake drill was conducted on 4/18/2023. Outdoor space/backyard was inspected and has a shaded area and sitting area. LPA observed one (1) broken bicycle and the Administrator stated that it will be removed and thrown away to keep the backyard free of obstruction.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (4) client bedrooms and (2) full bathrooms, a living room/activity area, office area, kitchen, dining area, backyard, and detached garage. Currently, there are three (3) clients living in the facility. Facility is Level 4. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. The window screen in bedroom #4 was broken with holes and detached from the window. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Detached garage is being used as exercise/activity area for the clients. Additional PPE supplies are also stored in the detached garage. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in a storage room where the laundry was located and inaccessible to clients. There are (2) fire extinguishers observed to be fully charged and was last serviced on 2/21/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. There are no cameras in the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 114.6 deg F in the kitchen, 118.2 deg F in bathroom #1 and 118.3 deg F in bathroom #2.