Facility Evaluation Report

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA knocked at the door and there was no answer. LPA contacted Administrator Mary Martin and explained the reason for the visit; Mary will have someone respond. LPA received a call from Mary and that staff would need 30 minutes to come out to the facility. Staff arrived at the facility and was not able to gain entry and had to leave, staff returned and LPA was able to gain entry at 3:01 PM into the facility. LPA learned that three (3) clients reside at this facility; all at program and there are currently one (1) caregiver present. There is no 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-not current, and TB test results, needs and service plans-not current, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

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.

Due to time constraints, LPA will need to return to complete the Annual. Based on the information received during this visit today in the areas reviewed, deficiencies will need to be addressed.

This LIC 809 report was reviewed with the facility representative and a copy was provided.