Facility Evaluation Report

Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. Facility has 3 bedrooms, 2 bathrooms, living room, kitchen, staff office, and an attached two car garage. In the backyard there is a one room building that is a therapy room, this building was part of the fire clearance report and is approved for use as a therapy room. LPA and staff toured the facility. LPA observed a seating area in the living room with a large screen TV. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry of the facility. LPA observed the facility license, facility certification certificate from the Department of Health Care Services posted next to the front entrance along with personal rights of residents/clients. The fire extinguishers in the kitchen and hallway are fully charged. The smoke detectors/carbon monoxide detectors tested operational. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply in the kitchen. LPA observed the medications and knives are kept locked in the staff office. Cleaning supplies are kept locked in the hall closet. LPA observed that the 3 client bedrooms had the required furnishings and bed linens. LPA observed both bathrooms are clean and operational. Hot water measured 115.0 to 118.5 degrees Fahrenheit in both bathrooms. LPA observed clean linens and towels stored in the hall closet. No obstacles or hazards observed inside of the facility. The garage has a portable air conditioner and is used as an exercise room. Staff reported that clients are not allowed in the garage without a staff member. The fire extinguisher in the garage is fully charged. LPA toured the backyard. There is a covered patio with shaded seating in the backyard. LPA observed the therapy room in the backyard. The therapy room is kept locked and it is only used with a client and a therapist. LPA observed the therapy room has a couch, desk and a chair. No obstacles or hazards observed in the therapy room. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA reviewed 5 client files and medications. No discrepancies observed. LPA reviewed 3 staff files. No discrepancies observed. All 3 staff had the required training including first aid training. LPA inspected the first aid kit. The first aid kit had all the required elements. The last emergency drill was conducted on June 19, 2024. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.