Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with House Manager Madonna Ganir. Clients were attending to Day Program.

LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 105.6 and 107.8 which is within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet. Medications are centrally stored in locked cabinet and medication records were reviewed. Fire extinguishers were last inspected October 2022. Smoke detectors and carbon monoxide detector are wired located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 6/7/23. Facility does have a current activity calendar and menu. Required postings were observed. First aid kit was fully stocked.

At 10:00am LPA conducted a file review of four client and six staff files. Clients records have updated care plans on file. CPR/1st aid certificates and training hours are current. Administrator Certificate for Dan Martin 6036010735 expired June, 2023. However, Administrator have proof that documents were submitted to CCL for renewal. Cash resources and documentation were reviewed.

Administrator agreed to submit updates of the following documents by 7/25/23: LIC500 (Personnel Report), LIC308 (Designation of facility responsibility), Surety bond, LIC400 (cash affidavit for clients) and lease agreement.

No deficiencies cited during today's inspection. Exit interview conducted with House Manager and a copy of this report was given.