Facility Evaluation Report

Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Required -1 Year inspection with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett. LPA met with Administrator Cami Hershkovitz.

During facility tour to inspect for infection control practices LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed. An inspection of the common area, resident rooms and restrooms were conducted. LPA observed the fire extinguishers fully charged. LPA observed hot water temperature at 116.6 degrees F. in resident bathroom. There is an adequate amount of perishable food. PPE supplies were observed. First Aid kit is complete. The smoke alarms and carbon monoxide detector were tested and were operable. Outdoor area toured- passageways are free of obstruction.

During facility tour at 12:02 pm with Administrator LPA did not observe a sufficient supply of nonperishable fruit as the facility had 2 large and 3 small cans of fruit.

During facility tour at 12:05 pm with Administrator LPA observed cannabis tincture CBD 250 mg THC 125 mg accessible to clients.

During facility tour at 12:17 pm with Administrator LPA observed a door leading to a hallway with 3 room additions which is not on the facility sketch. Administrator stated that they did get building permits for room additions.