Facility Evaluation Report

Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Richi Tamba. Rob Robinson Director Residential Services was contacted by phone and Frank Kremmeter arrived during this visit. Clients were in day program. There are activities planned for clients during the day if they want to participate.

LPA arrived at the facility and observed a check in for staff and visitor’s by the entrance door outside. During facility tour on 5/4/2022 with staff Richi and Frank facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 03/2022 at the time of the visit. Carbon monoxide detector and sample smoke detectors test was conducted and were operational during this visit. 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 closet in the hallway. There was a supply of cleaners, hygiene products and paper products available for clients. Sample of client’s bedrooms were inspected and had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucets measured between 113.9 degrees F and 121.8 degrees F in 2 out of 3 faucets failing out of Title 22 acceptable regulations of 105 to 120 degrees F. There was an upstairs bathroom that hot water temperature went up to 124.5 degrees F before coming down to 121/8. (LIC 809-D) Disaster Drills have been conducted monthly.

LPA observed facility is in good repair and free from hazards. Per staff alarm went off, client C1 stated that lamp was on fire, all clients were evacuated and staff grabbed the fire extinguisher and was able to put off the fire; while this was being done, client requested neighbor to contact 911 and fire department came over.