Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced required annual visit to the above facility. LPA met with staff and explained the reason for the visit. Administrator Dadesii Daniel arrived shortly after.

Record Review: At 11:00 a.m., a review of facility files was initiated. Facility records are stored in the locked office. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 09/05/2024). The LPA obtained Client Roster and staff roster. The LPA reviewed four (4) out of four (4) client files, including P&I money. The LPA observed five (5) out of eighteen (18) staff files. All documents reviewed appeared complete and current.

Medications: Medications review began at 12:50 p.m. for two (2) clients; medications are centrally stored and locked in a locked cabinet inside the locked medication room; medications are labeled and checked for expiration dates. The following was observed, during client #1's (C1's) review the LPA observed two medications not documented on the centrally stored medications and destruction record (CSMDR). Upon observation staff documented the medications. The LPA also observed C1's Olanzapine 5mg ODT with eight (8) days worth of medications, however based on the start date and quantity on the prescription label C1 should have five (5) days worth of medication. Upon observation, the administrator stated that C1 had recently visited their family and staff did not document the quantity C1 came back with. The LPA also observed that the quantity for all of the clients had not been documented on the CSMDR.

The LPA toured the physical plant areas inside and out starting at 3:00 p.m. which included testing the smoke and carbon monoxide detectors which functioned properly. The fire extinguisher was last serviced on 4/16/2024.