Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Backup Administrator Virginia Punzalan arrived later.

LPA initiated a tour of the facility around 11:30am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathroom used by residents measured at 130 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Kitchen cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. LPA observed a cabinet that was locked that had coffee and and other non-perishable foods along with knives. LPA questioned why the food was locked and staff explained that it is locked due to the behavior of a client. LPA and staff discussed alternative ways to address the behavior including, but not limited to, requesting a waiver to lock food and what would be required if facility chose to continue locking the cabinet. LPA confirmed that facility is not locking the refrigerator and that they provide meals and snacks per regulation. Medications were centrally stored and locked.

Fire extinguisher was last inspected May 2022. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent fire/disaster drill was conducted September 10, 2022. LPA notified staff that the requirement is now a Disaster Drill/Emergency Drill each quarter.