Facility Evaluation Report

Licensing Program Analyst (LPA) Anna Bueno and Program Clinical Consultant (PCC) Mirabelle Villamin conducted an unannounced visit to the facility for an annual inspection. LPA and PCC met with administrator Dianna Bonseigneur and two care staff. Director Quinn Reed arrived shortly.

LPA, PCC, and care staff toured the facility inside and out. This facility has no bodies of water. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. The outside of the facility had a shaded area with ample seating. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the laundry room, garage & underneath the kitchen sink. Medications were stored in a locked cart. Centrally stored medications and grooming supplies were kept in a safe and locked. Sharps were stored in a secured area. In the kitchen, food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) supply of nonperishable food items. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit and the last drills were conducted on 04/27/23 for fire and 03/15/23 for earthquake. The client bathrooms were operating in safe and sanitary conditions. Hot water within regulatory guidelines are being delivered in all. Emergency supplies were stored in the garage

LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and current certifications and training. Client files had the required documentation including an admission's agreement and current Individual Program Plan (IPP). LPA, PCC, and staff observed medications. Medications appeared to be dispensed appropriately according to the physician's orders.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Director Reed.