Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required 1 Year Inspection. This facility operates as a Social Rehabilitation Facility for persons with Mental Disabilities. LPA met with Leesa Durst-Weisman Administrator. Required postings were observed.

LPA/Administrator toured the buildings and grounds and observed the following: The facility was at comfortable temperature and exits free from obstructions. Bedrooms were furnished per regulation, hygiene and linen supplies were available. Hot water temperature measured between 105.4, 115.2, and 111.4 degrees F, which is within regulation of 105 to 120 degrees F. Fire extinguishers were charged and serviced March 2024. The facility has a hard wired sprinkler system; smoke and carbon monoxide detectors were available and functional throughout the facility. The last disaster drill was conducted on 9/5/2024. The facility does not have an evacuation chair yet. They just placed an order to get one (technical violation issued). The facility have at least two days of perishable and one week of nonperishable food supply, properly stored and handled per regulation. Medications centrally stored and locked in the medicine room. Medication and medication records were reviewed. Activity schedule and menus were observed. Facility do not handle cash resources.

LPA initiated file review at 9:15am. Seven client's files and five staff files were reviewed. Three out of seven clients do not have a medical assessment on file. All clients have their care plans updated. Staff have current CPR/1st aid and additional required training hours completed. However, one out of five staff (S1) do not have a health screening on file. Per Administrator, previous staff in charge of maintaining staff files updated did not obtain one for S1, but they will send S1 to have one done as soon as possible (technical violation issued). Continue on LIC809C...