Facility Evaluation Report

On 03/12/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Staff Member (SM), Phornsack Thevathath and explained the purpose of the visit. LPA asked that SM Thevathath call the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. Shortly after, LPA Pascua met with FDA Mai Xiong and explained the purpose of the visit.

Current census was 3. 2 out 3 residents were out at their respective day program at this time. 1 out 3 residents were observed to be napping upon arrival.

This facility is licensed to serve up to 4 residents who deemed ambulatory only. This facility is also vendorized by Valley Regional Center to hold and accept Level 4I residents at this time. A brief interview with FDA Xiong was conducted.

LPA reviewed 3 resident files and 5 staff files. All files were observed to be current and up to date. The Facility Designated Administrator currently holds an active administrators certificate #6050083735 and expires on 10/29/2024.

A tour of the facility was conducted. Fire extinguisher located in the kitchen and was serviced by

LPA observed a locked centralized stored medication cabinet located in the hallway. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.

Kitchen area was toured. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care.

A tour of the garage was conducted. Additional storage for supplies were identified. Additional food supply was identified.

A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time.