Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso arrived to conduct a case management inspection, on 3/21/24 at approximately 9:25am, and met with LPTs Lucy Campbell, and Judy Columbo. Administrator Susan Webster was contacted to notify them of LPAs arrival to the facility. This inspection is to follow-up on the Semi Annual Report recently conducted by CDDS. LPA reviewed the report findings with the Administrator, and requested additional information on specific items. The LPA also toured the facility.

It was identified by a professional contractor during the LPA's inspection that the surge protector, plugged into the outlet, was bad and no longer working. The surge protector was removed, and the LPA observed that the outlet was working properly. LPA observed that the second bathroom had a new shower head installed, and can be used if needed. There is a main bathroom with a large roll in shower for clients use, and this is the bathroom used for client bathing.

LPA conducted file reviews, observed staff had current training certificates in the file of required training. Per file reviews, there was a medication that was not being used for C1 upon discharge, 12/13/23, but was shown on the medication list; Per review this medication was a PRN, and was not included with discharged medications for C1. C1 had 12/19/23 follow-up Dr. appointment and this medication was not on the provided medication list.

The MAR record showed the medication on January and February records even though C1 was not prescribed the medication when discharged. Administrator followed-up and requested discontinue order due to the medication still showing up on MAR records.

Per file reviews, facility has centrally stored medication records and MAR records for documenting client medications, the records had required medication information.