Facility Evaluation Report

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the above-named facility. Tracy Jackson, Lead Quality Assurance Specialist (LQAS), Tri-Counties Regional Center (TCRC) accompanied LPA in the inspection. At the time of arrival, there were two residents in care and one staff member on duty. Administrator Wasantha Mohottige was present in the facility. One resident was out of the facility attending a day program.

LPA explained the purpose of the visit. The facility is a one-story home licensed as an Adult Residential Facility (ARF) for residents with a developmental disability and contracts with Tri-Counties Regional Center.

LQAS and LPA toured facility with Administrator.

A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the facility for fire safety, personal accommodations, and food service. A fire extinguisher is located in the kitchen area near the stove. The expiration on the extinguisher is 7/20/2035.

At approximately 10:29 am, Administrator, LQAS, and LPA observed the window screen in Bedroom 3 was pushed out of its frame and has a hole toward the top left corner of the screen. At approximately 10:33 am, Staff revealed burnt cigarette butts burned into the bathroom matt of the hallway bathroom.

LQAS and LPA observed four private bedrooms for the three residents residing in the facility.

The facility has 4 private bedrooms; Bedroom 4 has a private bathroom. The facility has a garage conversion for live-in staff quarters. The laundry room connects the staff quarters to the home.

Walls, floors, doors, and doorways are clean with no safety hazards. Hallways, bedroom doors and walls are in good repair. The kitchen area consists of a countertop area, a refrigerator, a stove, a microwave, and a sink. Sharps are kept in a locked drawer with no access to residents.

There is a sufficient amount of non-perishables for seven (7) days and perishables for two (2) days. The living room and dining area are in good condition. The facility maintains a comfortable temperature.