Facility Evaluation Report

On 4/11/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Administrator, Montel Jennings and Staff, Justine Reja. The facility currently provides care for 4 clients, two of which were present 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 Extinguishers were found to be last charged on 7/26/2023. Smoke and carbon monoxide detectors were interconnected found throughout the facility, tested and 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 were measured between 112.2 and 119.8 degrees F which is within Title 22 Regulations. Facility conducts and records emergency disaster drills once per month.

Medications are located in a designated cabinet shared with the laundry room and found to be secured. A spot medication count was conducted for client and found to be in order. LPA observed missing start dates on a client's centrally stored medication records, Technical Violation Issued. Medication administration records were also reviewed and found to be in order. 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 client record and found all documents including North Bay Regional Center Individual Program Plans and Physician's Reports to be current. There is a sufficient supply of linens, hygiene product and paper products available for client use. Items that could pose danger to client if accessible were found to be secured. Facility van was inspected and found to have appropriate emergency safety items including first aid kit and fire extinguisher. Clients were observed to have a positive relationship with staff and found participating in activities or meetings during the visit.