Facility Evaluation Report

Licensing Program Analyst (LPA) Dina Alviso, arrived to conduct a Required- 1 Year inspection and met with Administrator Reginald Catiis. This inspection will focus on the Infection Control procedures and practices of this facility.

Fire clearance is approved for thirty (30) non-ambulatory. LPA observed all exits free from obstruction. Fire extinguishers (2) were serviced and tagged as required, dated 2/23/22. Administrator has submitted the Infection Control Plan that was recently required; The Administrator stated that he will be submitting an addendum to the control plan regarding "monkey pox". There were 8 clients attending day program services during this inspection. There were seven(7) staff, and the Administrator on duty during the LPA's inspection. All visitors and staff are screened upon entry; Temperatures are taken, and screening questions are asked before being allowed to remain in the facility, all information is logged. Clients are screened daily, and observed for any changes, all information is logged. LPA observed the facility to be clean, orderly, and at a comfortable temperature. Toxins are stored in locked cabinets. There is a medication cabinet that locks making medications inaccessible to clients in care. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) for use by staff, visitors, and clients in care. Administrator and all staff were observed to be wearing appropriate masks during the LPA's inspection.

LPA observed two over the counter medication bottles of vitamin C, one large 1000mg and one small 500mg; The staff stated they were his personal bottles of Vitamin C. LPA discussed regulations regarding medications, including over the counter supplements, all are to be locked and secured at all times. This will be cited, Health Related Services 80075(j)(3)-see LIC89D.

The following deficiency was cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights provided to the Administrator.

Exit interview conducted with the Administrator.