Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and was welcome by back up Administrator Stephen Ngata. Clients were not present during the visit. They were at day program. Required postings were observed.

LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 106.7, 108.1 and 105.2 which is within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet. Medications are centrally stored in locked cabinet and medication records were reviewed. Fire extinguishers were last inspected October 2022. Smoke detectors and carbon monoxide detector are wired located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 2/28/23. Facility does have a current individualized leisure activity calendar and menu. Cash resources and documentation were reviewed.

At 9:00am LPA conducted a file review of four client and three staff files. Clients records have updated care plans on file. CPR/1st aid certificates and training hours are current. Administrator Certificate for Stephen Ngata 6029263735 expires 8/24/24. First aid kit was fully stocked.

Administrator agreed to submit updates of the following documents by 7/28/23: LIC500 (Personnel Report), LIC308 (Designation of facility responsibility), Surety bond, LIC400 (cash affidavit for clients) and lease agreement.

No deficiencies cited during today's inspection. Exit interview conducted with Back-up Administrator and a copy of this report was given.