Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required 1 yr. inspection to this facility and was welcome by staff Michael Francis. Administrator Michael Sus was contacted by staff and arrived during the visit. Clients had left to attend their day programs at the time of the visit. There are 6 clients in the facility.

LPA toured the facility on 6/16/2023 at 8:45 AM with staff Michael Francis, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/22/2022 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot water temperature measured between 109.7 degrees F and 111.2 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 client’s bathroom while touring facility on 6/16/2023 at 8:55 AM. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the facility kitchen. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads.

A review of five clients and a sample review of four staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 9:30 AM on 6/16/2023 and learned that 5 of 5 clients have an updated reappraisal/needs & care plan and physician’s report. P&I's are kept on a locked filed cabinet in the facility office room; facility responsible for all client’s P&I and money; facility had P& I and ledgers available during the visit. P& I money not comingle, and ledgers are current on 6/16/2023.