Facility Evaluation Report

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the 1-Year Annual Inspection on 6/20/2024. There were 2 carestaff, 1 maintenance director and 1 client at the facility at the time of inspection. 2 clients were attending their Day Program at the time.

LPA returned to review the facility records and personnel files. LPA had a discussion on 6/14/2024 with Licensee/Administrator after the Annual Visit on 6/13/2024 discussing the requirement that the Department is to have access to facility files at all times. Licensee/Administrator agreed to address the issue. On 06/20/2024 LPA was granted access to the facility and found the files immediately available for inspection. LPA was able to complete annual inspection and reviewed 5 personnel files and found them to be complete.

No deficiencies were found at the time of inspection and no citations issued.