Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Administrator, Shanice Moore. Clients were observed having breakfast.

LPA initiated a tour of the facility around 9:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client bathrooms measured at 109.4, 115.5, and 114.1 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Cleaning supplies are stored in a closet that was locked at time of inspection. Medications were reviewed, centrally stored and locked in the office. Fire extinguisher was last inspected April 2023. Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent disaster drills were conducted 11/26/23.

Three staff files and twelve client files were reviewed. Five out twelve client's care plan were not updated. One out of three staff do not have required First Aid and CPR certificates. Staff have required annual training hours. Administrator Certificate for Administrator Shanice Moore 6060870735, expired 10/25/2023. LPA confirmed ACS packet has been submitted, and re-certification is pending.

During file review, LPA/Administrator discussed the updated visitation and outing policy limiting client's visitations or requiring visitors to give 24-hour notice prior to arrival, which is not within Title 22 regulations regarding client's personal rights. Administrator agrees to review and ensure that all clients are given the right to have visitors each time the opportunity arises. Administrator will also update facility's visitation, outing policy and procedures regarding visitation and regulation 85072 that would require an update to the Admission Agreement and clients would need to agree to it.