Facility Evaluation Report

At approximately 8:40AM, Licensing Program Analyst's (LPA's) Julie Florio and Chris Arnhold conducted an unannounced Annual Required inspection at this facility and met with House Manager Rowena Radana. At approximately 9:00AM, LPA's toured the building and grounds which was found to be clean and in good repair. LPA's observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Fire extinguishers inspected were charged. Smoke detectors were tested and found to be in working order. Carbon Monoxide detector was present. Disaster Drills are conducted quarterly.

At approximately 10:00AM, LPA's reviewed 4 of 4 Client records and 5 of 5 Staff records.

1 of 4 Client records did not contain a care plan to address client behaviors. 4 of 4 client records did not contain functional capability forms. First aid and CPR certification were current in staff files reviewed. P&I monies were documented, secure and not commingled. LPA's observed the surety bond amounts were not correct. LPA's discussed with house manager that an updated Surety bond amount will need to be secured. Based on interviews conducted and records reviewed, the Administrator is not present in the facility to ensure facility is operating within regulation.