Facility Evaluation Report

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Mauna Morris. During the visit, LPA observed 19 residents and 5 staff.

LPA toured the reception area, activity room, staff kitchen, 2 bathrooms, isolation room, storage room, and 2 offices. The facility does not provide meals as clients bring their own meals and snacks from their respective homes. All rooms in facility noted to be clean and well maintained. All emergency exits noted to be clear of obstruction.

ADM stated she does not have any residents who taking their medication during their visit at the day program. Chemicals and toxins are locked in the storage room. Three fire extinguishers(inspected May 2024), smoke alarms, carbon monoxide detector and emergency first aid kit were observed in the facility.

All restrooms stocked with paper towels, soap, and paper supplies were observed to be available. Facility water temperature measured ranged from 109 degrees F to 112 degrees F. Facility was observed to have a designated quite room for residents to isolate if needed.

LPA reviewed facility records for 3 residents. While reviewing residents records, LPA observed that Resident R1's needs and services plan is dated February 13, 2020 and his/her IPP is dated February 10, 2022. LPA observed that Resident R3's Needs and Services Plan, dated May 15, 2019 and his/her IPP is dated May 4, 2020. LPA also reviewed 3 staff records. LPA conducted interviews with 2 staff and 1 resident.

LPA informed ADM the facility phone number does not connect. ADM stated she would send board of resolutions letter with updated facility phone number.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Mauna Morris and a copy of the signed report was provided.