Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility case management - legal/non-compliance visit (NCC). LPA met with Administrator, Bernellet Taa.

The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 07/26/2024.

During visit, LPA toured the facility with staff (S1) to include the living room, kitchen, dining room, 3 resident bedrooms, resident bathroom, staff bedroom, staff bathroom, Administrator's office, garage, and backyard. No cameras observed inside of the facility. LPA did not observe any concerns regarding the cleanliness of the facility.

There was only 1 caregiver/staff (S1) working in the facility upon arrival. LPA observed a total of 3 live-in individuals who are all fingerprint cleared and associated to the facility roster. 1 out of the 3 individuals (S1) is a staff/caregiver of the facility. The 2 live-in individuals are family members of S1 and does not assist with any caregiver duties. S1 states the 2 individuals just help to clean the facility.

Based on the facility's LIC500, the facility only has 2 main caregivers who work 7 days a week. S1 and S2 covers each other during break times to ensure the residents have staff supervision at all time. Based on the schedule and Administrator, there are certain times of the day where S1 and S2 are both present. Administrator is working on training another staff (S4) before starting work at the facility. A copy of the LIC500 obtained. SEE LIC809-C.