Facility Evaluation Report, 09/14/2023

On 9/14/23 at approximately 1:40pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Administrator Joyce Villanueva and explained the purpose of today's visit. The Administrator has an Administrator's certificate that is current.

LPA Jensen toured the grounds and observed all paths to be clear of obstruction. There is a large shaded are with outdoor furniture for client use in the front of the property and walk ways and garden beds in the backyard. The AC unit is located on the roof and is dripping water that is being directed in to a bucket on the ground. The AC unit is functional at this time.

LPA Jensen toured the interior of the facility. The facility was adequately lit and furnished. Toxins and knives are locked and inaccessible to residents in care. The carbon monoxide detector and smoke detectors were tested and are in compliance. The fire extinguisher was last serviced in June of 2023 and is in compliance. The first aid kit was determined to be complete. The water temperature was measured at 114 degrees Fahrenheit and is in compliance. The thermostat was set at 78 degrees which falls within the required regulatory range of 68-85 degrees Fahrenheit. The facility conducts regular fire drills. The emergency disaster plan was reviewed and is in compliance.

The facility currently has 4 staff members and 3 clients. 2 of 3 clients have restricted health conditions. All clients have special diets. The plan of operation was reviewed and technical assistance is being provided address consistency between the plan of operation and the restricted health care plans. All staff and client files were reviewed and determined to be complete and in compliance. A random audit of the medication was conducted and the record keeping was observed to be accurate. LPA Jensen also conducted an audit of P&I funds and determined the accounting to be accurate.

The facility has 4 bedrooms, 3 of which are for clients and 1 for live in staff. The client bedrooms were not equipped with chairs and technical assistance is being provided.