Facility Evaluation Report

08/28/2024, Licensing Program Analyst (LPAs) Loera and Felias conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently six(6) clients in care. Upon arrival three(3) out of six(6) clients were at day program. Facility approved/cleared for two non-ambulatory.

At approximately 9:30am, LPAs and Director toured the building and grounds. The facility was found to be at a comfortable temperature with all exits free of obstruction. LPAs observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

All rooms were equipped with lighting, night stand, and drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured 112.1 within the range of 105 to 120 degrees F. Fire extinguishers were last inspected May, 2024. Smoke/Carbon Monoxide detectors are hard wired and located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were located in a locked cabinet in the kitchen and found to be secured.

LPAs conducted spot medication check and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. P&I monies were documented, secure and not commingled.

At approximately 10:30 am, LPAs conducted a review of six client records. All records had the required documentation.

At approximately 11:00 am, LPA conducted review of four(4) staff records/training. Upon a review of staff records, LPAs found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.