Facility Evaluation Report

Licensing Program Analyst Simi Rai conducted an unannounced Required 1 Year visit and met with Program Manager (PM) Lauro Centeno. LPA observed 9 staff and 25 residents in the activity room of the facility.

During visit, LPA toured the facility inside and out. Sharps and medications were locked in secured areas.

The facility restrooms had available soap, paper towels and hand sanitizer. Hot water temperature was tested and measured 105.2 - 107.6 F degrees. Exercise equipment was also observed. Refrigerators were available to store clients' food in the kitchen area.

Fire extinguisher was observed and inspected on January 18th 2023. Facility smoke detectors and carbon monoxide detectors were in working condition. First aid kits were inspected and observed compliant to regulations. The facility's last disaster drill was not documented but PM stated the facility participated in the Statewide Shake Out this year.

LPA Rai reviewed 5 client files. LPA reviewed Client's Medication Administration Record for 2 clients, R1-R2. During review of R3's client file, R3 did not have a copy of the Admission Agreement, LIC 613 Personal Rights and consent form on file.

LPA Rai reviewed 5 staff files. LPA Rai reviewed S1's staff file, S1 does not have criminal record clearance and health screening report. PM stated the facility was aware of a background clearance but was not aware of S1 not having criminal record clearance. LPA Rai informed PM of S1 not working in the facility until criminal record clearance is obtained.