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25 | On today's date Licensing Program Analyst Javina George made an unannounced visit to the facility for the purpose of conducting a 1 year required visit. LPA met with Administrator Zoe Wilson and explained the purpose of the visit. At the time of the visit there were (0) clients present as they were all at the day program. There was a total of (2) staff present. All staff present were observed to have obtained criminal record clearance and were associated to the facility.
LPA conducted a tour of the interior and exterior of the facility. The facility is a single story home consisting of (4) bedrooms, three (3) bathrooms, backyard with a covered patio, garden, garage, basketball court, craft area and living room. The facility was observed to be clean and clutter free, and has plenty of activities to encourage and promote socialization. The passageways are free and clear from obstruction. There are no pools or bodies of water or known guns or ammunition on the premises. The facility has a fully charged fire extinguisher. The facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items. The facility was observed to have an ample supply of personal protective equipment (PPE). The facility also has emergency food and water. The smoke and carbon monoxide detectors were tested and found to be operable. The hot water was tested and was found to be within regulatory limits measuring between 105.9-107.2 degree Fahrenheit. The sharps and chemicals are stored in a locked cabinet kitchen sink. The medications are stored in a locked cabinet inside the kitchen. The medications were reviewed and are being given according to the physician instructions as verified per the Medication Authorization Record (MAR). The facility was observed to have the required postings such as license, personal rights, theft and loss, and CCL complaint poster).
LPA conducted a review of staff records staff had valid CPR/First aid certification, and active administrator certificate that expires on 12/18/25. The facility will submit a change of administrator packet, as well as a copy of liability insurance, to place in the facility file at the regional office. Client files had the required documentation such as medical assessment, IPP, admissions agreement. Personal and Incidental (P&I) funds were verified an accounted for. The facility is completing emergency drills on a quarterly basis, and the last drill conducted was on 3/27/24, next scheduled drill is 6/27/24. In addition the facility conducts random fire drills on a monthly basis. Based on today's inspection, no deficiencies were observed. An exit interview was conducted and a copy of the report and LIC 811 was provided to Zoe Wilson, Administrator. |