Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for four (4) non-ambulatory clients. LPA met with Administrator Monaliza Dela Rosa . At the time of the visit, two clients were present at the facility.

LPA toured the facility inside and outside. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured 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) day supply of nonperishable food items. LPA toured the client bedrooms. 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 available and the last disaster drill was conducted on 4/14/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Centrally stored medications were kept in a safe and locked cabinet. LPA toured the client bathrooms. LPA measured the hot water temperature in the bathroom. The hot water temperature measured 115 degrees Fahrenheit. LPA observed emergency supplies in the garage. The outside of the facility had a shaded area with a table and chairs. The facility does not have a pool or bodies of water.

LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Administrator file lacked the required HIV and TB training as required every 2 years. Administrator stated it has expired and they will have to re-enroll for certification. Deficiency issued. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. LPA observed the signs and postings in the common area. LPA did not observe the facility policy on visitation. Administrator stated they do not currently have one in place but will work on having one created. Deficiency issued. LPA observed the Emergency Disaster Plan (LIC 610D) was posted, however was not updated as of 2020.