Facility Evaluation Report

Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Fred Arias arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted at the facility by facility staff. LPAs met with Lenette Belen, Administrator and explained the purpose of the inspection.

The facility is one-story building with 4 client rooms, 2 bathrooms, kitchen, dining room, living room, staff room, enclosed patio, den, laundry area, office area, backyard and 2-car garage. All client rooms had the required elements, including bed, chair, closet space and ample lighting. LPAs observed the facility to be in good repair. LPAs observed two exit gates that are self-latching and unlocked. Facility has toxins, chemicals and cleaning supplies locked in a cabinet in the laundry area. LPAs observed sharps to be locked in a drawer in the kitchen. Restrooms are stocked with soap, paper towels and air dryers. LPAs observed facility has emergency food and water supply as well as additional emergency supplies. LPAs observed the fire extinguishers are full as indicated by the meter on them. LPAs observed the service tags on the extinguishers stating they were serviced in April of 2024. LPAs reviewed 5 staff files and 4 client files. LPAs reviewed the P&I and medication for all clients. Based on medication review, LPAs observed handwriting on a client's prescription label. Facility staff stated the label was written on by facility staff. A deficiency is being issued. Facility staff could not provide LPAs with a medication administration record for a client's PRN medication taken. A deficiency is being issued. LPAs conducted interviews with 4 staff. Clients present were non-verbal and unable to be interviewed by LPAs. Based on review of the facility's emergency disaster plan, LPAs determined the disaster plan to be incomplete. A deficiency is being issued. LPAs issued a Technical Violation regarding Admission Agreements. LPAs provided advising on Admission Agreement policy. Facility staff was advised to draft a new Admission Agreement for the facility that includes all Title 22 Requirements and to have clients and/or their responsible parties sign these new Admission Agreements. Facility staff was advised to maintain both agreements in client files.

Based on today's inspection, three deficiencies and one technical violation are being issued. An exit interview was conducted and a copy of this report, deficiency pages and appeal rights were provided to the facility.