Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 5/31/24. LPA met with Staff, Edwin Offor, and explained the purpose of the visit. The administrator, Janet Obong, arrived shortly after to assist with the visit. The facility is licensed for 4 non-ambulatory adults, ages 18 - 59, of which 1 may be bedridden. Bedrooms #1 and #3 are approved for bedridden. There is currently 3 clients residing at the home.

LPA toured the facility and used the Compliance and Regulatory Enforcement (CARE) tool to do the inspection. The facility consists of 3 client bedrooms, 1 staff room, administrator's office, 2 bathrooms, living room, dining area, kitchen, and attached garage. The outdoor has a shaded area for client use. Each client bedroom has sufficient lighting and closet space. Extra linens are stored in the closet. The carbon monoxide detector is located in the hallway. Smoke detectors in each room are interconnected. Staff are continuing to follow the infection control plan and wearing gloves while assisting clients. Knives and cleaning supplies are locked in the drawers. There is sufficient food supplies of 2 day perishable and a week of nonperishable items.

LPA reviewed 3 Client files. The files contain the required documents such as the admission agreement, consent forms, medical assessment, TB results, Property/Valuable forms, and client rights. The P&I ledgers were also reviewed for each client. Medications for all 3 clients are being administered as prescribed. The facility has the client rights and complaint posters posted in prominent locations. Clients are provided with internet services. There are no clients with a restricted or prohibited health condition.

LPA reviewed 3 personnel files. The administrator's (Janet Obong) certificate expires on 12/23/24 and HIV/TB certificate was issued on 6/17/23. Staff files have the required documents and are receiving on-going training. CPR & First Aid certificates are all current.

The emergency disaster plan is posted and is easily accessible by staff. LPA provided a technical advisory for the disaster drills.

No deficiencies issued today. An exit interview was held and a copy of this report was given to the administrator.