Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:35AM. Also present during today's visit was Tri Counties Regional Center Quality Assurance Specialist (QA) Liz Aced-Arnett. The LPA met with Administrator Ramona (Mona) Keeton. LPA explained the reason for today's visit. Entrance interview conducted.

The facility is vendored through Tri-Counties Regional Center as a level 3 home. LPA reviewed the following:

STAFF FILES: LPA reviewed three (3) staff files for, but not limited to: fingerprint background clearance, health screening, TB test, and training records. All three (3) staff files reviewed were in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted monthly, with the last drill conducted on 10/19/2023. Emergency disaster plan was observed to be complete and updated annually, however, the facility is utilizing the older form. LPA provided the updated form during the visit.

CLIENT FILES/CASH RESOURCES: LPA reviewed both client files for, but not limited to: physician's report, proof of TB test, Admission Agreement, and cash resources. All two (2) of two (2) client files reviewed were complete and contained all documentation required.

MEDICATION REVIEW: Beginning at 11:32AM, LPA reviewed medications for two (2) clients. All medications reviewed were documented and stored in compliance with regulation.