Facility Evaluation Report

License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1-year Infection Control visit of the facility. LPA was welcomed by Case Manager Tina Stanford, LPA spoke via phone to Interim Administrator Connie Mann. There are 5 clients currently at the facility.

The facility has six client bedrooms. Random bedrooms were inspected. There are two bathrooms for clients that were inspected. The hot water temperature in client’s bathrooms measured at 113.3 degrees F and 114 degrees F within Title 22 regulations of 105 degrees to 120 degrees F. Toxic cleaning supplies are stored in a locked closet located in the laundry room. Perishable and nonperishable food supplies were sufficient to Title 22 Regulations of 2 days of perishable and 7 days of nonperishable. Knives are kept locked in drawer in staff office area. The kitchen and dining area was organized and free of clutter. The facility is well lit with a comfortable ambient temperature. The facility was clean and well maintained. There is a large multipurpose room used for client meeting and activities. A large seating area where clients may congregate, or staff are able to hold group meetings is located off the kitchen/dining area.

The facility has a locked medication room. Medications are stored in a locked cabinet within the room. There is also a metal locked box stored within the medication cabinet for any medication that requires a third lock. The Facility has a multi pull station fire alarm with audible/visual notification. Facility has fourteen integrated carbon monoxide/smoke alarms and sprinklers are tested annually by A.S.T.I Services Inc. last tested 11/29/2022. Fire extinguisher was found to be last charged on 11/30/2022.

Facility has submitted a Mitigation Program and Infection Control Plan. Clients come from CSU and are tested for COVID (must be negative) before coming to facility but are only at facility for a maximum of 21 days and or in an emergency 28 days. Posters have been placed at facility. Facility has PPE supply stored in a locked closet adjacent to the front desk and in a drawer at the front desk. Staff have had PPE training and have been N95 Fit Tested.