Facility Evaluation Report

Licensing Program Analyst (LPA) LaVette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility DSP Foster Lupupa and was granted entry to the facility. LPA asked DSP Foster to notified the administrator and let her know of my arrival. The administrator stated she would be arriving soon. At the time of the visit there was one (1) staff present, two clients living in the home, both client were at the Day Program. The facility is a four (4) bedroom, two (2) bathroom home, with a kitchen/dining area, living room, attached garage, with a lock gate on the right and left side leading to the backyard. During the visit the Administrator arrived, which was Melanie Morris. LPA was escorted by DSP, Foster Lupupa, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested at 120 which is within regulation. LPA advised the administrator to conduct a routine check to ensure the temperature does not increase. The facility is equipped with operating smoke detectors and carbon monoxide alarms. They were tested and found to be in working. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside a locked cabinet inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. The facility has a fire extinguisher, and it was inspected on 11/22/2024. The facility performs monthly fire and earthquake drills, the last drill was conducted on 03/2025. LPA observed the facility did not complete the annual review of the emergency and disaster plan, a technical violation was issued.