Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Martinez is conducting this annual/random visit. LPA arrived at the facility was greeted and granted entry to the facility by Arjhun Garcia Lead Direct Care Staff and LPA explained the nature of the visit.

Two clients reside at this facility. LPA upon entry observed one client in living room waiting for day program transportation. LPA began the tour of the inside and outside of the facility. LPA observed required department postings through out the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in attached garage in refrigerators. The facility is maintained at a comfortable temperature. LPA inspected that mediation are centrally stored in a safe locked storage closet adjacent to living room. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA measured the hot water temperature which measured 112.8 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 underneath kitchen sink and in garage inaccessible to clients. 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 shaded seating areas for client’s enjoyment. LPA observed a fire extinguisher with service date of 2/25/23 mounted on the wall of dining room. Fire drills conducted every 1-3 months and LPA verified last Fire Drill was conducted on 5/01/23. LPA began review of records. LPA reviewed two clients’ records. All the required documentation was present and current in client’s files reviewed. The facility P&I records were reviewed. LPA observed that an