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 Staff #1 (S1) Carla Ibarra and discussed the purpose of the inspection. Administrator (AD) Ingrid Wilson appeared via telephone.

LPA reviewed Infection Control requirements. At about 9:45AM, LPA and S1 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 a 2-bedroom, 2-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 3 staff and 1 client present at the facility. Client Bedrooms: the 2 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at between 106 and 109 degrees F in the common 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. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 10:45AM, LPA reviewed 2 client files and 3 staff files, interviewed 1 client and 1 staff, and inspected medications for 2 clients. The facility does not handle client money.

During the inspection, LPA and S1 observed the following: based on documents, S2 is not background cleared and has been working at the facility since 09/09/23. During the inspection, the licensee removed S2 and confirmed S2 will not return until they are background cleared and associated and LPA confirmed.