Facility Evaluation Report

On September 13, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra arrived at the facility at 09:15 AM to conduct the Annual 1-year required inspection. LPAs met with the Program Director, Dao Do, and Program Manager, Shanah Hawk, and explained the purpose of the visit.

LPAs toured the physical plant and observed it to be clean and odor-free at a comfortable temperature and adequate lighting. This single-story building has a main activities area, 4 activity classrooms for arts, physical therapy, computer lab, and music, a dining room, a kitchen, 2 gender specific restrooms, 3 private restrooms, and an outdoor patio area. The outdoor patio area was fully enclosed and is used for gardening plus other outdoor activities. There are 3 exterior doors at the facility and delayed egress devices on these doors were observed to be operational. No accessible bodies of water or fire safety/tripping hazards were observed.

LPAs observed toxins, cleaning supplies, and sharp objects were stored/locked properly and inaccessible to the clients. No cooking was observed at the facility. The Program Director specified that clients’ lunch is catered through the Meals on Wheels nutrition program and is brought to the facility in the morning. Staff warms the food in the kitchen area before serving the lunch . The Refrigerator in the kitchen is used to store clients’ lunch if they bring from home.

The bathrooms were observed to be clean and equipped with trash cans, grab bars, liquid soap, and paper towels. An emergency call system is installed in all the bathrooms, and signals/alarms from them are monitored at the reception desk. The bathroom faucet water temperature was measured at 116.4°F.

Participants were observed sitting in the main common area, engaged in activities, singing, and dancing. LPAs reviewed 5 random participant files and 5 random staff files. All were observed to be complete. The client’s medications were securely stored in a locked container/cabinet in the nurse’s room.