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32 | Operational Requirements: Fire Drills are not conducted every three months; the last fire drill was conducted on 8/23/2023. Emergency Disaster/ Earthquake Drills are also not conducted every three months and the last one was conducted on 08/2023. Facility Administrator will conduct drills quarterly.
Physical Plant & Environment Safety: The home is located in a residential area, the single-story facility includes a living room, dining room, kitchen, laundry room, 4 client bedrooms, 2 restrooms, an attached garage and indoor/outdoor activity areas. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, all beds have adequate amount of linen and mattresses, and box springs are in good repair. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. Bathroom sinks and showers were free of mold/mildew. LPA observed that sufficient toiletries accessible to clients. Water temperature measured between 117.3-134.0 degrees F which is not within range of 105.0 – 120 Degrees F. Facility temperature was comfortable. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detectors were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher(s) are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. Exits were marked with signs. Notifications and postings were observed which included personal rights, facility sketch, visitor policy, complaint procedures, menu, and emergency disaster plan.
Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-S4. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator Certificate is current and expires on 07/11/2025.
Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services for facility clients.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources. Special Incident Reports, Client Personal Property and Clients Personal Rights and current IPPs for the exception of C1 who needs updated IPP. Last one was completed on 06/16/2021
Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1-4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly. PRN authorizations letters are missing for 2 clients.
Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services but R2 that has a restricted health condition and has a plan on file that has been reviewed and approved by physician and Regional Center.
Disaster Preparedness: The facility has an Emergency Disaster Plan but needs updating.
Emergency Intervention: Not Applicable.
Deficiencies noted. Technical advisories also provided. Exit interview and a copy of this report, 809D and appeal rights was provided to Administrator Jennifer Oglesby
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