Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Elizabeth Wise. Clients were attending to celebration program. Required postings observed.

At approximately 9:00am LPA and Admin toured the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Bedding observed to be clean and in good repair. Water temperature in client bathrooms measured at 113.1 and 112.6 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two [2] days of perishable foods and seven [7] days of non-perishable foods. Food was found to be stored in a safe manner with open items covered and labeled. Emergency supply of food and water present.

Medications are centrally stored and locked. At approximately 12:00pm LPA and Admin did a spot check of medications and medication records were reviewed. Facility utilizes a MAR, LPA reviewed MAR entries, no discrepancies observed. During spot check of medication, LPA and Admin observed one bottle of Fluticasone exp date of 6/20/2024, had expiration date incorrectly entered on Centrally Stored Medication log (CSML) and one bottle of Ketotifen exp date of 1/1/2025 also had expiration date incorrectly entered on CSML. Per Title 22 regulation 80075(k)(7)(F) Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: (F) Expiration date ( deficiency cited, see 809D ).