Facility Evaluation Report

Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection and case management duo to a recent death at this facility was welcome by staff Leonjae. Paula Sifflet is the Regional Manager for the corporation arrived at facility for visit that was conducted. Staff also contacted administrator Sherri Lott who spoke on the phone with LPA during this visit. Clients were present during the visit. There is no day program at this time, however; there are activities planned for clients during the day if they want to participate and outings.

During facility tour 9/8/2022 with staff, 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 06/2022 at the time of the visit. 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 refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored locked under kitchen sink. LPA observed that dangerous items were locked. 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 faucet measured 107.8 degrees F in 1 out of 1 faucet within Title 22 acceptable regulations of 105 to 120 degrees F.