Facility Evaluation Report

On 6/25/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by House Manager, Alex Macajola. The facility currently provides care for 6 clients, all of which were attending day program at the time of visit. LPA continued with a tour of the facility with House Manager. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 3/12/2024. Smoke and carbon monoxide detectors 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 with appropriate storage and labeling. Water at faucets accessible to clients were measured at 108.8 degrees F which is within Title 22 Regulations. Facility conducts and records emergency disaster drills every other month and found 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. Upon inspection LPA observed light switch in hallway in need of repair due to client tampering. In addition, LPA observed outdoor backyard patio in need of general cleaning due to animal droppings. Facility to provide photo corrections of repairs and cleaning. Technical Violation issued.

There is a secured staff office were medication is stored which was found to be secured. Spot count of medication was conducted and found to be in order with records found to be completed. LPA conducted a review for staff files and found all staff to have 1st Aid & CPR certification and annual training on file. LPA conducted a sample review of client files and found all items to be in order. LPA found that 6 out of 6 client files are nearing for updated Needs & Service Plans/Individual Program Plans. The facility is currently in the process of updating the items for file.

LPA requested the following documents be sent to CCL by COB 7/25/2024:

LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s

No deficiencies cited during today's visit.