Facility Evaluation Report

On October 11, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Program Director, Dao Do and explained the purpose of the visit.

During visit, there were 51 clients and 11 direct support professionals present.

LPA toured the facility and grounds, no accessible bodies of water or fire safety hazards observed. LPA toured the physical plant including but not limited to client restrooms, classrooms, activity area, art room, music room, kitchen, dining room, and outside area. Classrooms were observed to be clean and free from tripping hazards. LPA observed the mail classroom (great room) to be spacious. Residents were observed to be listening to music during the visit. LPA observed two private bathrooms and two separate communal bathrooms observed for women and men. Bathrooms were clean and equipped with liquid soap, paper-towels, and grab bars.

LPA toured the kitchen. Program Director stated kitchen door stays locked at all times. Sharps were observed to be stored appropriately and inaccessible to clients. According to the Program Director stated that clients' lunch are provided by Meals On Wheels program and brought to the facility in the morning. Staff warms the food in the kitchen area prior to serving lunch.

Medications were observed in a locked container in the nurse's room inaccessible to clients. Door to the nurse's room is in a locked area which is only accessible by staff. LPA observed fire extinguishers to be full and last serviced on 4/2023. First aid kit was observed to be present. Chemicals and toxins were observed to be in a locked shed in the outdoor area.

LPA reviewed 6 client files and 6 staff files. All staff are fingerprint cleared and associated to the facility. Files were observed to be complete.

No deficiencies are cited during the visit. Report is reviewed with Program Director and a copy is provided.