Facility Evaluation Report

On 8/25/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of an annual continuation visit and was greeted by Administrator, Ashley Johnson. Facility provides care for 4 clients all of which were on outings or attending day program at the time of visit. LPA conducted a sample file review of staff and found all staff to have updated 1st Aid & CPR training certification on file. In addition, LPA conducted a file review for all clients (C1, C2. C3 & C4) and found clients to have updated Physician's Reports and Needs & Service Plans or Individual Program Plans from North Bay Regional Center.

Upon a review of client files, C1 was found to have an updated 1:1 ratio care supervision plan. Facility staffing is currently sufficient to meet the level of care for all of the clients in care. Facility is currently partnered with an outside staffing agency and is provided one additional agency Direct Support Staff. LPA was informed that the facility has recently transitioned to the RELIAS system to conduct staff training. Upon review of training LPA found that staff have completed several hours within the RELIAS system however several training hours were not indicated on the staff transcripts. Administrator to contact RELIAS to reconcile training hours.

LPA conducted a spot medication check and found 1 out 1 client C2's medication not indicated on the Centrally Stored Medication form. However, upon review of C2's Medication Administration Records, the medication, prescription order and start date was indicated. Administrator agrees to conduct a medication audit and reconcile records. Technical Violation issued. Lastly, LPA conducted a review of client P&I and found monies to be in order and not commingled.

No deficiencies cited during today's visit.