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25 | 01/21/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently six(6) clients in care. Facility approved/cleared for 1 non-ambulatory. Upon arrival LPA observed construction being done at the facility with no clients or staff present. LPA made a call and House Manager arrived at approximately 1:00pm. Per conversation with House Manager, the facility is getting new flooring. Construction should be done in approximately two weeks.
LPA conducted a review of 3 client records. All records had the required documentation. LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.
LPA and House Manager toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner.
Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens are available in the hallway closet. Water temperature in sinks accessible to clients in care were measured at 111.9 and 109.0 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 02/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility conducts monthly fire and disaster drills with the last one being done 12/28/2024. Knives were located in a locked drawer in the kitchen. Toxins and cleaners are located in a locked hallway closet. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Client cash resources were reviewed.
No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/21/2025:
LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC309- Administrative Organization
Exit interview conducted with House Manager and a copy of this report was provided. |