Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for completing a required annual inspection. LPA arrived at facility was greeted and granted entry by staff. LPA met with Michael Yamashiro, Operations Manager the nature of the visit.

Four clients currently reside at this location and clients were at in the community at the time of visit. LPA accompanied by Operations Manager began the tour of the inside and outside of the facility, facility is a two-story home. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. LPA toured the kitchen and food storage areas. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food stored in garage refrigerators and pantry. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in a safe locked storage closet in med room. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA measured the hot water temperature which measured 106.8 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored and locked in storage cabinets. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is several seating areas for client’s enjoyment. LPA observed a fire extinguisher with service date of March 17, 2023, mounted on the walls throughout the facility. Fire drills conducted quarterly, and LPA verified last fire drill was conducted on January 16 & 19, 2023. LPA began review of records. Records are kept electronically and were made available to LPA. LPA reviewed two clients’ records. All the required documentation was present and current