Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon arrived at 12:20 pm to conducted a case management annual continuation visit to the facility above. LPA met Administrator Guadalupe Ramirez and explained the purpose of the visit.

Staffing: The facility employes 8 staff and 1 Administrator. Staff records are kept confidential and locked in staff office. LPA reviewed 4 random staff files and 1 Administrator file. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for meeting the Continuing Education requirements, HIV/TB training completed and LPA verified Administrator on the ARF Certification list as pending.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff files had initial and annual training's, All staff had current First Aid/ CPR training, and current CPI training certifications.

Clients Rights: All require postings were posted in the common area of the facility. Personal rights of Persons with disabilities, Personal Rights, and Non-discrimination notice. CCL Complaint poster is posted at entry. The current license along with CCL reports and PIN's were in the staff office. Visitation policy is posted at entry. Internet is provided to each client and each client is given confidentiality and privacy.

Clients Records & Incident Reports: The facility keeps separate files on each client confidential locked in staff office. Four files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS) which facility utilizes the Individual Services Plan (ISP) and contains the same information and is completed annually, TB results, Personal Rights and Safeguard for property and valuables. The Facility does handle cash resources for all clients in care. Facility Surety Bond is current and expires 10/01/2023. LPA audited all four clients cash resources, ledger, receipts and balances were all present and correct. Facility does submit incident reports to the department when required. Continued 809-C