Facility Evaluation Report

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Members, Terry Keady and Jenny Boris. Team Leader, Zasha Daep, arrived during visit at approximately 10:00AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance and capacity for 10 Ambulatory Clients. Upon arrival, LPA were informed that there were 10 clients in care and 2 staff members on-site.

At approximately 9:15AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Staff Members. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 3 story building with 5 Client bedrooms, 4 bathrooms, 1 staff room, 2 staff offices, and common spaces. Facility has Infection Control Plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were found to be out of compliance with Title 22 regulations of 105 to 120 degrees Fahrenheit, measuring at 135.3F, 132.6F, 129.3F, 123.6F, and 132.6F (deficiency cited, LIC809D, regulation 80088(e)(1)).

LPA reviewed staff and client files and client medication. Files were all found to be well organized, thorough and contained the required documentation. Facility does not manage money for clients. Staff files had current First Aid and CPR certification. During medication review, LPA and Team Leader observed that some medications were not documented in the centrally storage log as required (technical violation issued, regulation 80075(k)). Team Leader understands that all medications received by the facility must be logged with the expected information such as the Fill Date and Start Date.