Facility Evaluation Report

On 09/24/2024 at 11:55 AM PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with administrator Irene Ogbeiwe. LPA explained the purpose of the visit. The current census is 4 with 1 facility staff.

This facility is a single story building licensed to serve 3 ambulatory and 1 non-ambulatory clients. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client’s bedrooms, client’s bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting.

LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. LPA observed knifes kept and made inaccessible to clients in care. Hot water temperature was measured at 119.1 degrees Fahrenheit in client bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the dining room and was last serviced on 05/29/2024. The last fire drill was conducted on 09/20/2024. LPA observed the facility has a has a public telephone in the common area. Facility thermostat observed at 75 degrees Fahrenheit. LPA observed toxins kept locked and inaccessible to clients. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA reviewed and compared 4 out of 4 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all the required components. LPA requested client and staff files for review. LPA reviewed 4 out of 4 clients files and 2 out 2 staff files, and they were complete.

As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted, and a copy of these LIC 809 reports were provided to the facility.