Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to complete the annual inspection. LPA met with Staff Samson Iwajomo and explained the reason for the visit. The initial visit was held on 4/25/24.

During the visit today, LPA continued the remainder of the CARE tool domains. The following were observed:

Staffing: Per administrator, there is sufficient staffing and an awake staff for the overnight shift to provide supervision.

Personnel Records-Training: Administrator (Akinwale Orunesajo) certificate expires on 6/11/25 and the HIV & TB certificate was issued on 2/5/23. LPA reviewed 3 other staff files and they have the required documents on file. They are receiving on-going training and medication training every year. Staff have current CPR & First Aid certificates.

Clients Rights-Information: Clients are provided with internet access.

Client Records-Incidents: LPA reviewed 4 client files and they all have the required documents such as admission agreement, medical assessment with TB test results, client rights, personal valuable and cash resource forms. Clients have current IPP and behavioral assessments on file.

Health-Related Services: Clients medications are centrally stored and locked. All 4 clients' medications were reviewed and are being given as prescribed.

Incidental Medical Services: There are no clients with restricted or prohibited health conditions.

Disaster Preparedness: Facility has the updated LIC610D Emergency Disaster Plan with emergency procedures listed. There are at least 2 relocation sites and directions to turn off valves.

Emergency Intervention: Staff have CPI training and do not utilize any restraints on clients.

There are no deficiencies observed during the visit today. An exit interview was held and a copy of this report was given to the administrator.