Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with Administrator and explained purpose of visit.

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, client bedrooms; client bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water temperature in client's bathroom at degrees Fahrenheit which is within the required range of 105 to 120 degrees.

Fire extinguishers last inspected on 2/8/2023. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to clients. LPA reviewed and compared client medication vs. medication logs. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 12/26/2023.

Licensee has been following restricted health care plan approved on 4/14/2023 for client - C2 (See LIC 811 Confidential Names). Valley Mountain Regional Center (VMRC) service coordinator has documented C2's continual refusal of medications for condition of diabetes on individual program plan last documented on 12/5/2023. Therefore no need for deficiency for not following restricted health care plan. Primary doctor, VMRC, and client are aware of the health risk factors involved.