Facility Evaluation Report

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Staff Members, Gilbert Mishiame, and Bibi Okoye. Licensee/CEO, Barrett Adams, arrived during visit at approximately 10:15AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 4 Ambulatory Clients. Upon arrival, LPA was informed that there were 4 clients in care with 1 client out of the facility attending Day Program, and 1 client attending Day Program via Zoom. LPA was also informed that there was two staff members on-site.

At approximately 9:30AM, LPA reviewed the Facility's Staff Roster. LPA found that Staff Member 1 (S1) was still not associated to the facility as required. Facility provided LPA with email correspondence with Guardian regarding S1's association to the facility. LPA provided Licensee/CEO with LIC9182, Transfer Request Form, in order to associate S1 to facility. LPA was provided with the paperwork and S1 will be associated to the facility roster at the Santa Rosa Regional Office. At approximately 10:00AM, LPA reviewed staff files, client files and client medications. Staff files had current First Aid and CPR certification. During File Review, LPA observed the following: Staff Member 2 (S2) did not have a health screening or proof of negative TB test on file (technical violation issued, LIC9102, regulation 80066(b)). LPA also observed the following items missing from client files:

Client 1 - missing admissions agreement, consent forms, personal rights, and pre-assessment

Client 2 - missing medical assessment, proof of negative TB test, personal rights, and pre-assessment

Client 3 - missing personal rights and pre-assessment

Client 4 - missing personal rights and pre-assessment

(deficiency cited, see LIC809D, regulation 80070(b)).

During medication review, LPA observed that the facility uses a written Medication Authorization Record (MAR) and a centrally stored log. LPA observed that some medications were not documented on the log as required. Per Licensee and staff members, facility has a nurse that fills out the centrally stored log every month (see technical violation, LIC9102, regulation 80075(k)(7). Facility does not manage/handle money for clients.