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32 | Continued from LIC809...
Facility's fire extinguishers were observed charged and were last serviced 1/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts monthly disaster drills, and the most recent drill was conducted 1/2025. LPAs observed facility's infection control plan and emergency disaster plan which was last updated 1/2025. LPAs observed a supply of PPE, emergency supplies, a first aid kit, flashlights, and two (2) backup generators for emergency preparedness.
At approximately 11:45 AM, LPAs reviewed four (4) staff files and four (4) client files. Four (4) of four (4) staff files reviewed have all the required paperwork and proof of current First Aid and CPR training. Four (4) of four (4) client files reviewed have all the required paperwork. Facility coordinates medical and dental visits for the clients and takes them to and from their appointments.
At approximately 1:00 PM, LPAs reviewed medications and medication records which are maintained and stored in compliance with regulation. LPAs reviewed P&I monies and logs, which were organized and maintained and stored in accordance with regulation. However, LPAs observed facility carrying more cash than stated on their LIC400 Affidavit Regarding Client Cash Resources and more than they are bonded to carry. Administrator immediately obtained an additional Surety bond to bring the facility into compliance with regulation.
Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
LIC500 - Personnel Report (updated)
LIC400 - Affidavit Regarding Client Cash Resources
No deficiencies cited during today's inspection.
Exit interview conducted with Administrator, whose signature on form confirms receipt.
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