Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting an Annual Required inspection and met with Coordinator, Stephanie Thueson. Participants were observed at Day Program engaged in activities. The Day program operates Tuesdays and Thursdays from 10am to 4pm.

LPA/Administrator initiated a tour of the facility at 11:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. The activity schedule for the day was written on a white board. The day program operates out of a primary room within the 490 Mendocino. Meals are provided by Meals on Wheels and contracts with the facility to serve participants. Participants have the choice to bring their lunch. Program maintains a supply of coffee for snacks. There is one bathroom available for participant use. Bathrooms were equipped with grab bars to ensure safety. Toxins were inaccessible. Facility does not handle cash and medications. The facility does not provide transportation. The smoke alarm system is maintained by the building manager in 9/23. Most recent Disaster drill was conducted 10/16/23. Carbon monoxide was tested and operational. Water temperature in bathroom measured at 115 degrees F which is within allowable range of 105-120 degrees F.

- At approximate 11:20am LPA/Administrator observed fire extinguisher was last inspected July, 2022.

File review was initiated at 11:30am. Two staff files and five participant files were reviewed. Staff have required First Aid and CPR certificates. However, 2 out of 2 (S1 & S2) staff did not have 8 hours of annual training required hours. 3 out of 5 participant's (P1, P2 & P3) did not have an updated care plan. Also, 2 out of 5 participants (P2 & P3) diagnosed with dementia did not have a current medical assessment on file.

Administrator submitted updates of the following: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Emergency Disaster Plan (LIC610E).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator & copy of report was given .