Facility Evaluation Report

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection. LPA met with Administrator Romario Luckhoo. There were 4 staff and 7 residents on site at the time of inspection. Other staff and clients were out in the community.

Facility was found to be clean, orderly, and at a comfortable temperature of 72 degrees F with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored and locked in a small med room making them inaccessible to residents and staff that do not handle medications. Staff received training on medication administration on 6/18/2024 due to recent error and a new system for informing staff of medication changes has been implemented. All bathrooms were clean and in good working order, with soap and paper towels. There were 3 carbon monoxide detectors and 7 smoke detectors that were tested and operational at the time of inspection. There were 6 fire extinguishers last serviced on 10/24/2023.

The facility's grounds were found to be well cared for, with lots of containers of flowers and vegetables. Residents help with the care of the facility and the animals on site, including ducks, sheep, goats, a pig, chickens and farm cats.

LPA reviewed 3 resident files and found them to be complete, with ample notes and documentation. LPA also reviewed 5 staff files and found them complete; staff training was well documented and easy to track. LPA also went over last DHCS report and found plans of correction had been enacted and completed.

No deficiencies found at the time of inspection. No citations issued.