Facility Evaluation Report

Licensing Program Analyst (LPAs) Hanna Gough and Michael Tea arrived at the facility to conduct an unannounced Required 1-Year Inspection. LPAs were greeted and granted entry by staff. LPAs informed Administrator (AD) Abdol Arastoo the purpose of the inspection.

The facility is comprised of two buildings. Building A is a one-story building with five client bedrooms, three bathrooms, kitchen, medication room and a dining room. Building B is a one-story building with eight client rooms, three bathrooms and a laundry area.

All residents rooms had required components and furnishings. Facility had extra clean linens in a cabinet in building B. The facility has extra linens for clients in hallway cabinets. Restrooms are stocked with soap and paper towels. Hot water in Building A measured between 105.8-110.3 degrees Fahrenheit. The hot water in Building B bathrooms measured between 107.7-112.1 degrees Fahrenheit. LPAs observed the kitchen to be clean and free of debris. LPAs observed a 7 day non perishable and 2 day perishable supply of food. LPAs observed the emergency food and water supply located in the kitchen. The kitchen has a door that locks making sharps inaccessible to clients in care. LPAs observed all fire extinguishers in building A and building B to be fully charged with a service date of March 15, 2024. LPAs observed the centrally stored medication in a med room located in the dining room. LPAs observed toxins and chemicals are locked in a closet in building B and inaccessible to clients in care. The backyard has a shaded seating area for client use and is free of debris and obstructions. LPAs reviewed four of four client files and no discrepancies were observed. LIC 859 provided. LPAs reviewed two staff files and no discrepancies were observed. Staff trainings were not logged and accounted for during LPAs review of records, a type B citation was given on this date. LIC 858 provided. LPAs reviewed P&I log with AD and observed that the funds were not separated per regulations but was all accounted for. A technical violation was given on this date. LPAs reviewed four client medications and no discrepancies were observed.