Facility Evaluation Report

On 9/3/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met Program Director Micah Sutton and explained the purpose of today's visit. It was learned that the Executive Director/Administrator separated from the company with the final day on site being July 26, 2024. There is no formal replacement designated at this time.

LPA Jensen toured the grounds and observed the paths to be free of obstruction. There is a shaded outdoor area and outdoor furniture for client use. There are no bodies of water on the property. Outdoor activity areas are adequately distanced from traffic to ensure client safety. LPA Jensen toured the interior of the facility including common areas, bathrooms, break rooms, kitchen, instructional rooms and offices. All rooms were observed to contain adequate lighting and furniture. All toxins were locked and inaccessible to residents in care. The water temperature in shared bathrooms was within the required range. The thermostat was set at 72 degrees for the comfort of the clients. There was no expired food observed. The facility maintains numerous first aid kits that are complete and in compliance. The facility has an automated external defibrillator (AED). Staff are appropriately certified in AED use. The fire extinguisher and carbon monoxide detectors were tested and found to be in good working order. The emergency disaster plan was reviewed and found to be in compliance. All exits were clearly marked. LPA Jensen engaged with numerous clients during the course of this visit. 3 clients were interviewed and 3 of 3 parties interviewed confirmed they are satisfied with all aspects of the program. LPA Jensen interviewed 3 staff members. All staff members interviewed were able to adequately answer questions related to meeting client needs and mandated reporting. LPA Jensen reviewed 2 staff files and 2 client files and found them to be complete and in compliance.

Technical Assistance is being provided on AED regulations and client oxygen use. A deficiency related to the facilities lack of an Administrator is being issued pursuant to the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies can result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided