Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was met by Staff Margaret Henley who contacted Administrator Katrina Williams and arrived at facility later. Five of six clients were present at the facility as the final client was at on the job training with his case manager.

At 1:25 pm LPA arrived at the facility and had her temperature checked and logged. All staff are temperature checked and logged each shift and wear masks. During facility tour on 8/26/2021 with staff Margaret Henley, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 08/23/2019 at the time of the visit. Smoke Detectors & Carbon Monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked closet in hallway closet. Medications are stored locked and inaccessible to clients in a locked standalone cabinet in the dinning room that also contains client’s files. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Hot water temperature measured between 119.5 degrees F which is within acceptable regulations of 105 to 120 degrees F in client’s bathroom faucets.

Administrator & Staff’s 1 st Aid and CPR certificates are at another facility locked up and will send copies of current certificates to LPA Dominic Tobola by end of month (Tuesday 8/31/2021) to prevent a citation.

Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small stand with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in hallway closet & garage. Facility has a 30-day supply of medication for clients. Clients are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit.