Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by staff. Leilani Mae Dagdag, Administrator arrived shortly after and met with LPA. LPA explained the nature of the visit to Administrator.

Four clients reside at this facility, all clients were at the facility at the time of visit. LPA accompanied with Administrator began the tour of the inside and outside of the facility. LPA observed required department postings throughout 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 a spare refrigerator in the garage. The facility is maintained at a comfortable and cool temperature. LPA inspected that medication are centrally stored in a safe locked storage cabinet. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA inspected facility bathrooms and LPA measured the hot water temperature which measured 105.6 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 locked in a cabinet located in the garage. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. 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 June 15, 2023, in the kitchen. Fire drills conducted every three months and LPA verified last fire drill was conducted on June 02, 2023. LPA began review of records. LPA reviewed four clients’ records. All the required documentation was present and current