Facility Evaluation Report

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Elizabeth Halahan and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 2:00PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is an 8-bedroom, 3-bathroom, one-story house with attached garage that is being used for storage. There is a back yard with a patio cover for the clients and a pool that is properly gated. LPA observed 2 staff and 6 clients present at the facility. Client Bedrooms: the 6 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are 2 staff bedrooms which are kept locked. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 118.5 and 120 degrees F in the 2 client bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the storage closet. Toxins: observed locked in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 3:00PM, LPA reviewed 5 client files and 5 staff files, interviewed 2 clients and 2 staff, inspected medications for 5 clients, and inspected client money and ledgers for 5 clients. During the inspection, LPA and AD observed the following: based on documents, the licensee has only completed the Regional Center's admission agreement with all clients and has not completed their own admission agreement with any clients. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.