The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

Infection control practices, signs, and Personal Protective Equipment (PPEs) were observed. LPA observed Infection Control Plan is in file.

Physical Plant/Environment Safety:

The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of three (3) ambulatory only clients between the ages of 18-59. It consists of one (1) shared client bedroom, one (1) private client bedroom, a living room, dining room, a kitchen, two (2) shared client restrooms which client restroom #1 had a hot water temperature reading measured at 124.8 Degrees F, and the client restroom #2 which had a hot water temperature reading of 113.5 Degrees F, shaded back patio area, and a staff room. Bedrooms have the required furniture including bed, bedframes, linens, dressers, lamps, and nightstands. Beds have the required linens and the linens are in good condition. LPA observed half bed rails in the two (2) beds in the client shared bedroom. Clean Linens observed in the hallway closet. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility has one (1) fully charged fire extinguisher kept in the living room.

Carbon monoxide detector is tested and in working condition. Sharps were observed in a drawer with plastic fasteners which was it’s not locked, not secure, and easily opened which can be accessible to clients. Cleaning supplies were in a cabinet under the kitchen sink with plastic fasteners and easily opened, not kept locked, not secure and can be accessible to clients.

Operational Requirements:

The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for three (3) ambulatory only clients age ranges 18 through 59.

Staffing:

A total of two (2) full-time staff members provides care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificate on file expires on 06/05/2025. Recent HIV and TB training certificate not in Administrator’s file. LPA reviewed Administrator and S1 files. Personnel records have criminal background clearance, health/TB screenings, certifications, and CPR/AED training were reviewed. Administrator and S1 does not have valid First Aid training on file.

Client Records/Incident Reports:

No client files were reviewed since there are no clients in care.

Food Service:

The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Cleaning supplies and insecticides were found unsecured underneath the kitchen. No restricted Health Care plan required for the clients in the facility since there are no clients in care.

Health Related Services:

No centrally stored client medication records were reviewed since there are no clients in care.

No clients medical and dental records were reviewed since there are no clients in care. Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

LPA observed a current Emergency and Disaster Plan LIC 610D was not on file at the facility. Based on record review and interview, an emergency fire and disaster drill was not on file.

Emergency Intervention:

No manual restraints or seclusion are used at the facility and there are no clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, technical violations observed during the visit are documented. Exit interview held and a copy of the report were provided to S1.