Facility Evaluation Report

License Program Analyst (LPA) Shannan Hansen arrived at 12:00 PM to complete an unannounced annual inspection and met with Janet Kirby, Licensee. There is a total of 2 clients.

LPA reviewed centrally stored medication record, staff and client records to complete this annual inspection. On 10/19/2022 LPA conducted a case management of facility and gave a technical assistance requesting required Infection Control Plan that was originally due on 6/30/2022 be submitted by 12/19/2022. The department has not received Infection Control Plan, facility is being cited on Regulation 85095.5(c) (see LIC809-D) Department is also requesting an updated facility sketch indicating additional room on first floor with LIC200.

LPA Hansen is requesting Licensee to update and submit the following documents by 5/15/2023 to SRRO:

LIC 308 Designation of Facility Responsibility

LIC400 Affidavit Regarding Client Cash Resources

LIC 610 Emergency Disaster Plan (if changes)

The following deficiencies were observed (see LIC 809D) and 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. Exit interview conducted and appeal of rights provided..