Facility Evaluation Report

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry by Roquesa Tuazon. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that three (3) clients reside at this facility that includes one (1) currently at the hospital and there are currently one (1) caregiver and Administrator present. There is an Infection Control Plan on file.

Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Three (3) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/and Staffing- LPA began review of employee records- Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 01/28/2026.

Medications - are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. There are no clients that receive P&I currently.