Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/17/2023 at 09:24 a.m. LPA was granted entry and met with staff, Ivy Kasko, who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (0) client present.

The facility is a two (2) story home with (8) bedrooms and (4) bathrooms with attached garage. No pools or firearms are being kept at the facility. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.

Physical Plant: LPA observed the client bedrooms and staff bedrooms. LPA observed the posted floor plan and the submitted floor plan did not match the current physical plant. The "loft" area on the second story was observed and confirmed by staff to be converted to (2) bedrooms. LPA observed these bedrooms were being used for staff. The licensee will receive a citation for this, and plan of correction was documented for this. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients in locked drawer. The smoke detector and carbon monoxide was operational, and the hot water temperature 106F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.