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25 | At approximately 9:30 AM, Licensing Program Analyst (LPA) Shannan Hansen conducted an unannounced Annual Required inspection to this facility and met with Administrator Mariah L. Uden. At approximately 9:45 AM, LPA toured the building and grounds which was found to be clean and in good repair, although client bathroom 1 to have bathtub tile fixed and cleaned and client bathroom 3 to have shower cleaned and floor in front of shower door repaired. TA given. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secured and not accessible to clients. Medication is centrally stored and secured in the office. There is a sufficient supply of hygiene products and linens on hand for client use. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. 2 Fire extinguishers reviewed were charged and inspected 02/07/2023. Smoke detectors and Carbon Monoxide detectors were tested and found to be in working order. Facility has pull station for fire alarm. Disaster Drills are conducted quarterly with the last being a fire drill conducted on 02/18/2023.
At approximately 11:00 AM, LPA reviewed 3 out of 6 Client records and 2 of 4 Staff records, which were all found to be well organized, thorough and contained the required documentation. First aid and CPR certification were current in staff files reviewed. Facility does not hold P&I monies. Administrator's Certificate was current with an expiration date of 07/30/2023.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/11/2023 :
LIC308- Designation of Responsibility
LIC500 Personnel Report
LIC610D- Disaster Plan
LIC 9020 Register of Facility Client’s
No deficiencies were found in the areas inspected, No citations issued during today's visit.
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