Facility Evaluation Report
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. No staff was present upon LPA arrival to facility at 10 a.m. LPA emailed Administrator Maria Simon to please call when available. Administrator Maria Simon did call and text that she would be headed back to the facility. LPA Hurt met Administrator Maria Simon back at the facility at 11:00 a.m. and, Continual Administrators certificate expires 03/06/2025. There are currently 4 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.
Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA reviewed facility client files, and facility staff files. LPA reviewed facility infection control plan, and facility Emergency Disaster Plan.
LPA observed facility resident hallway sink water measured at 134 degrees. Staff 1 did not have file available for review. Staff 2, and Staff 3 did not have required TB/ Health screening in personnel file. Resident 1 does not have updated Needs and Services Plan.
The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.
LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.
Exit interview conducted with Administrator Maria Simon, and copy of report left at facility
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction