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25 | Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that zero (0) clients live at this facility and there is currently one (1) staff member present. The Caregiver, Tinisha Sherley (S1) conducted the facility tour. There is an Infection Control Plan on file.
Client Records-Incident Reports/Clients Rights-Information/Dental- LPA would have reviewed client records. Zero (0) records were reviewed. LPA would have reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.
Personnel Records/Training/and Staffing- LPA began review of employee records- Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Synthia Marie Luna’s Administrator’s license, expiration date is 09/14/2022. The Administrator certificate was submitted on 08/15/2022.
(Continued on LIC809C)
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