Facility Evaluation Report

On 9/19/2024, Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Inspection of this Adult Residential Facility and was greeted by Staff, Jacqueline Bearden. Administrator, Zina Lee was contacted and arrived during visit. The facility currently provides care for 3 clients, 2 of which were present, leaving for day programs at the beginning of visit and 1 of which was attending day program at the time of visit.

At approximately 9:00 AM LPA toured facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 9/25/2023. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. Water temperature in faucets accessible to clients was 136.4 degrees F falling out of regulatory range of 105 degrees to 120 degrees F (see LIC 809-D) Administrator turned down during inspection. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food stored in the garage. Food stored in the kitchen refrigerator were stored properly with appropriate labeling and dates. There was a supply of linens, hygiene products and paper products available for clients located in the hallway.

At approximately 9:45 AM LPA conducted a file review for 3 out of 3 clients. Clients' (C1) did not have copy of TB (see LIC 809-D). The Needs & Service Plans for all clients have been updated as of January 2024. At approximately 11:00 AM LPA conducted a sample file review of 3 staff and found all staff to have appropriate training, 1st aid & CPR certification on file. Although 2 staff (S1 & S2) did not have required Health Screening or TB tests (see LIC 809-D). In addition, facility conducts emergency evacuation drills with staff and clients every three months with the last conducted on 6/5/2024.