Facility Evaluation Report

Licensing Program Analyst (LPA) Jessica Cho continued the visit unannounced after a conducting the 10-day complaint investigation in connection to Complaint Control Number: 22-AS-20240314164054. The purpose of this visit was to conduct the required annual inspection. LPA was assisted by Program Director Andrew Crawford and explained the reason for the visit.

This facility is a two-story residential home comprised of three client bedrooms, two client bathrooms, one staff bathroom, formal living/family room, dining area, kitchen, laundry room, medication office, a therapy shed in the backyard, and a two-car garage. LPA observed clutter of items that was blocking the passageway in the garage. LPA toured the outside grounds. There was shading and sufficient seating for the clients. LPA observed one exit gate was not self-latching. LPA observed that the client bedrooms had all required elements with ample lighting. LPA observed the floor of the shared client bathroom had accumulation of debris that will require a deep cleaning, the wall by the toilet had a hole, and a sharp metal object was exposed. Showers, faucets, and toilets were sanitary and in operating condition. The hot water temperature measured at 118.2, 113.9, and 113.1 degrees Fahrenheit in all bathrooms. There were sufficient and clean supply of linens. LPA observed ample two-day supply of perishables and seven-day supply of non-perishables. LPA observed the emergency food/water. The carbon monoxide and smoke detectors were tested and operational. One auditory device in the medication office was not operating at the time of the visit. The fire extinguisher was securely mounted and serviced on June 29, 2023. Medications, sharps, and toxins were locked and inaccessible to the clients.The following items were all posted and available for review: an incomplete Emergency Disaster Plan (LIC610D), food menu, client rights, Complaint Poster (PUB475) posted in the entry way. LPA reviewed five out of the five client files/medications and three staff files during today's visit. A medication discrepancy was observed during the review of the Medication Log for Client #1. LPA and PD Crawford reviewed the client's funds and noted that the expenses were not being updated into the facility's system.