Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA arrived and met with Administrator, Janet Obong.

LPA conducted the following domains during the visit today:

Staffing : There is sufficient staffing at the facility with at least 2 staff in each shift. The overnight shift staff are awake. Staff are fingerprint cleared and associated to the facility. Personnel Records-Training : Staff files are maintained at the facility. Administrator (Janet Obong) certificate expires on 12/23/24. The administrator training on HIV/AIDS and TB had expired on 4/12/23 and the CPR/First Aid certificate had also expired on 3/6/23. LPA reviewed (2) additional personnel files and they have the required documents.

Client Rights - Information: Clients are afforded privacy and provided devices with internet access.

Client Records-Incident Reports: Client files are maintained at the facility. LPA reviewed all (4) client files. Client #3 was missing current TB test. Client #3 was admitted to the facility on 5/28/22 and the TB test result on file was dated 7/26/19. The other client files have the required documents. Health-Related Services: The medications are centrally stored and locked. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all 4 clients and they are being administered as prescribed by the physician. Incidental Medical & Dental: There are no clients who require health services or have a health condition that need to be monitored more carefully. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Staff are provided training on the emergency procedures and know where the utility shutoff valves are located. The client roster is posted and the clients' face sheet have been updated.

The deficiencies are issued on the LIC809D page. An exit interview was held. A copy of this report, appeal rights, and LIC809D were given to the administrator.