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The facility’s swimming pool was locked/secured behind a fence and gate meeting regulatory requirements. There were no hazardous objects, active fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Per the Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. A complete first aid kit was present and readily accessible. Required licensing postings were observed in visible areas of the facility.
However, the facility was not in a state of general cleanliness. (For example, cobwebs were seen inside a kitchen cabinet. Kitchen cabinets had a film of grease on the outside. The shower and toilet shared by clients showed debris and/or visible staining. Interior floors showed dirt. There was unused debris/refuse in the facility’s backyard and near the front driveway). Also, the window screen in Bedroom #3 was worn and needed to be replaced. Multiple trash cans/containers did not have tight-fitting lids, as was required.
LPA reviewed administrative records, staff files, and client files. LPA also interviewed multiple facility staff and clients. Client interviews did not raise any licensing concerns. During records review, LPA observed, and manager interview confirmed: For full-time Staff #1 (S1), Licensee did not have for them a current LIC503 Health Screening (or equivalent document) and negative tuberculosis test result, as was required. S1 corroborated that they did not yet undergo those steps, despite having worked at the facility since the preceding year. Licensee did not maintain personnel files for on-call caregivers Staff #2 (S2) and Staff #3 (S3), both of whom have worked at least once in the last quarter. Licensee also did not maintain personnel files for Staff #4 (S4) and Staff #5 (S5), who performed support tasks at the facility. Per review of CCLD’s database: S3 and S5 were not associated to the facility’s employee roster. There was also one non-client and non-staff adult living on the premises (P1) who was not associated to the facility’s roster, as required. (LPA’s research showed: S1 through S5, and P1, had each been fingerprinted and possessed current criminal record/background clearances with CCLD.)
[CONTINUED ON LIC 809-C, 2 of 2] |