Facility Evaluation Report

At approximately 11:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Pre-Licensing visit and met with Herby Mathurin, Licensee/Applicant . Applicant has applied for a Change of Ownership for an existing Adult Residential Facility identified as 4 Seasons 486804123 . Facility currently provides care to adults with developmental and intellectual disabilities and is vendorized with the North Bay Regional Center (NBRC) as a level three (3) care facility. LPA was informed that there is currently one (1) client in care who was out of the community with their mentor during today's visit.

At Approximately 11:05 AM, LPA conducted a physical plant walk-through. LPA observed the following: The facility is a one-story home with four (4) client bedrooms, two of which are currently being used as staff bedrooms, two bathrooms, and a common area. Facility was found to be clean with all exits free from obstruction. Facility had emergency lighting. LPA observed required postings including the CCL Complaint Poster and Personal Rights for Individuals with Developmental Disabilities. Facility has an Infection Control plan and Emergency Disaster Plan on file. LPA observed a supply of at least two (2) days of perishable and and seven (7) days of nonperishable foods as required by Title 22 Regulations. Emergency supplies, water, and a first aid kit were observed in facility garage. Toxins were observed to be stored inaccessible to clients. There was a supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. Facility received an approved fire clearance on 08/15/2024 for three (3) Ambulatory and two (2) Non-Ambulatory clients. Facility purchased a new fully charged fire extinguisher March 2024. Smoke and carbon monoxide detectors were tested and operational during today's inspection. Facility phone was tested and operational during inspection.

At approximately 12:00 PM, LPA conducted file review and found the following: three (3) of three (3) staff/Licensee files reviewed had current First Aid and CPR certifications as well as all the required paperwork. One (1) of one (1) client files reviewed had all the required paperwork. Medication was observed to be centrally stored and secure. Client files were located in a locked cabinet. P&I was stored and maintained in compliance with regulation.

At approximately 12:40 PM, LPA conducted Component III with Applicant. LPA notified Applicant that once licensed, they will need to complete a new Admission Agreement and Care Plan for the current client in care.