Facility Evaluation Report

On 9/21/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Administrator, Regyna Jackson-Brandcomb. The facility currently provides care for 3 clients, all of which were attending day program at the time of visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 7/5/2023. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients was measured at 111.8 degrees F which is within Title 22 Regulations. LPA observed facility restroom flooring to have minor water damage and in need of repair. There is no indication of hazard or risk of slipping based on observation. The facility has already contacted maintenance manager who has quoted the repairs and scheduled to return by 9/27/2023 for completion. LPA also observed the garage door handle on the inside of the facility and a single fence panel in the side yard both in need of replacement. Technical Violation issued for follow up on repairs.

Facility conducts and records emergency disaster drills on a monthly basis. Medications are located in a designated cabinet located in the hallway and found to be secured. A spot medication count was conducted for clients and found to be in order along with properly documented centrally stored medication records. LPA conducted a review for staff files and found all staff to have 1st Aid & CPR certification and annual training on file. In addition, LPA reviewed all client records and found all documents including Needs & Service Plan, North Bay Regional Center Individual Program Plans and Physician's Reports to be current. All clients attending day program are currently provided transport to and from the facility directly from the day programs. There is a sufficient supply of linens, hygiene product and paper products available for client use. Client P&I funds were also observed to be secured and not commingled.