Facility Evaluation Report

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 4/19/2023 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Administrator, Michael Ligpit, and explained the purpose of the visit. LPA observed five (5) clients present at the facility.

At 12:30 PM, LPA reviewed a total of three (3) client files. Client files contain signed admission agreements, physician's reports, identification sheets, releases, individual program plan (IPP), and client rights. LPA reviewed clients' PNI money and found it to be accurate. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for three (3) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff records. Staff has training in medications, first aid and CPR, and other various areas of care provision.

At 1:30 PM, LPA and administrator toured the interior and exterior of the facility to ensure health and safety of clients s in care. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, two (2) bathrooms, kitchen, and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. Toxic and cleaning supplies locked and is inaccessible to clients in care. The hot water temperature was measured in the kitchen at 106 degrees Fahrenheit. First aid kit was completed. LPA observed fire extinguisher/carbon monoxide alarms to be in working order and the fire extinguisher to be last service 11/22/2022.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.