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25 | On 6/13/23 at 11:15 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced Annual/Required visit. LPA met with Kylan Reynoso, Administrator, and explained the purpose of the visit.
LPA toured the facility with the administrator. There were no clients in the facility nor other staff besides the administrator. Administrator states that clients are at day program. The facility is maintained in conformity with state fire marshal regulations. Smoke detectors and carbon monoxide detectors were tested and functioning properly. Fire extinguishers (3) were located in the kitchen (2) and at the end of the hallway near client bedrooms. Extinguishers were fully charged and last inspected on 11/22/22. There are no pools or bodies of water and no firearms or dangerous weapons stored. Hot water temperature measured at 113.7 F degrees in resident bathrooms (2). All toilets and hand washing facilities are maintained in a safe, sanitary, operating condition. The facility is clean, safe, sanitary and in good repair for the safety and well-being of clients, employees, and visitors. Each client is accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs. There is a minimum 2-day supply of perishables and 7-day supply of nonperishable foods. Food is stored and prepared in a safe and healthful manner. Disinfectants, cleaning solutions and poisons are inaccessible to clients. The facility has adequate emergency supplies and first aid supplies. Facility temperature is 71 degrees F. Outdoor walkways are free from obstruction and the facility has outside areas for individuals to use. The gate on the right side of the property to/from the backyard is missing an automatic closing mechanism. Licensee will add the mechanism to the gate, take a video and send to LPA by 6/20/23. Centrally stored medication is kept secure in a locked cabinet in the living room and inaccessible to clients. Medications are given as prescribed by doctors’ orders, however, the most recent Centrally Stored Medications List for Client #1 (C1) was dated 6/1/22. Deficiency cited. Emergency disaster drills are conducted monthly. LPA reviewed (5) staff files for criminal record clearances and associations, Health screening with TB results, and current First Aid/CPR. Staff records reviewed are in-compliance. LPA reviewed (2) client files for current needs and services plans and signed admission agreements and personal rights. All files are in-compliance.
Exit interview conducted, deficiency cited, and the report and appeal rights given.
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