Facility Evaluation Report

Licensing program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to conduct the annual required visit. LPA knocked on door and no answer. LPA contacted staff by telephone and was greeted at the door at approximately 12:50 and granted entry into the facility. Facility is licensed for 6 ambulatory clients and the facility currently has 6 clients. Ruby Lipio has an Administrator Certificate expiring on 07/02/2024. Licensee/Administrator Henry Balanza arrived during the visit.

LPA Lyman along with Administrator Ruby Lipio toured the facility at 1:00 PM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of four client bedrooms, one shared hall bathroom, client restroom, staff restroom, two staff rooms, living room, dining room, and kitchen. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 110.12 and 111.3 degrees F in facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and Carbon Monoxide detectors tested operational during today's visit. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for clients. Exit gates are unlocked and operational. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan as well as infection control plan during the visit. Plans are thorough and complete. Facility has emergency disaster packs for clients as well as additional emergency supplies. Facility provided documentation of last fire drill conducted on 05/27/2024 and drills are conducted monthly. Facility provides activities in the form of games and outings in the community. At 1:30 PM, LPA reviewed six client files and two staff files. Client files contained required documents including admission agreements, physician reports and client appraisals. Staff files reviewed contained required documentation of training and criminal record clearance. Both staff files reviewed contained CPR certification. CONTINUED ON LIC 809C DATED 05/29/2024.