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25 | On 10/23/24 at 8:30 am Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced himself, stated the purpose of the visit, and was greeedt by Brigida Sengsiri, Licensee (L1). LPA was granted entry. 1 client was present upon arrival and was waiting for Day Program pickup. The other 5 residents had previously departed for Day Program.
LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good condition,, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. A sample of resident’s medications were checked and observed kept locked in medication cart. Clients’ MARS was reviewed. Cleaning chemicals was observed stored and locked in facility. Fire extinguisher was observed with a service date of: 11/5/23. Fire drill last completed on 7/1/24. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested 110 degrees F in bathroom 1, 110 degrees F in bathroom 2 and 110 degrees F in bathroom 3.
Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature was maintained range at 0 degrees F and refrigerator temperature was maintained range at 41 degrees F. Carbon monoxide and smoke detector were tested and observed to be operational. All clients’ files reviewed to have all the required documents. Samples of staff files were reviewed to have all required documents.
No deficiencies issued during this inspection.
Continued on LIC-809C
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