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25 | At approximately 12:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and Administrator, Lakeda Brown-Steward. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed that there were 5 clients in care with 3 clients out of the facility attending Day Program. LPA was also informed that there were two staff members on-site.
At approximately 12:40PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 12:50PM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 4 Client bedrooms, 2 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were measured at 98.2F, 97.4F, and 96.7F (this deficiency has been cited, see LIC809D, Regulation 80088(e)(1)). Facility has a swimming pool that was observed to be locked. Per conversation with Administrator, staff have water safety certificates in the event clients want to go swimming.
At approximately 1:00PM, LPA reviewed staff files, client files, client medication, and client P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. During medication review, LPA observed that one client had pre-poured medication (see technical violation, LIC9102, Regulation 80075(k)(5)). Per conversation with Administrator, client is able to store and administer their medications but at this time, facility is storing the medication for them. Review of client's 602 indicated that they are able to store and administer their own medication. LPA informed Administrator that facilities are unable to pre-pour medications. Administrator stated that they will assess client's ability to manage their own medications and if client is unable to manage their medication appropriately, client's physician's report will be updated to where facility manages the medication.
Continued on LIC809C
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