LPA, along with Program Manager, toured the facility to ensure client health and safety and the facility is in compliance with Title 22 regulations. The following was observed:

Fire extinguishers were observed to be fully charged and last serviced 11/16/2023. Hardwired combination smoke and carbon monoxide detectors were tested and were functional at the time of the visit.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food to accommodate clients for 7 (seven) days and perishable food for 2 (two) days. Knives and other sharps are stored in locked kitchen drawers and cabinets. Cleaning supplies were observed locked under the kitchen sink. There were no visible immediate hazards observed.

COMMON AREAS: The facility consists of 3 stories - the entry level and two lower levels. There are common areas found on each of the 3 (three) levels, including a Dining Room, living room, Art Room, and sitting area. All furniture appeared clean and in good condition.

TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: There is a Group Room, Staff Office and Nurse's Office/Medication Room on the entry level. The medication room was observed to be locked and contains a locked medication cart. At 12:44PM, medications were reviewed for 2 (two) clients. Medications observed were properly labeled and medication records observed were documented per regulation. The First Aid Kit is stored in the Medication Room and was observed to be complete. The ground floor also contains an individual therapy room. The Offices are kept inaccessible to clients unless properly supervised.

Report Continued on LIC 809-C

BEDROOMS: There are 4 (four) bedrooms, of which 2 (two) are private bedrooms and 2 (two) are designated for shared use. Bedrooms are located on the lower level and ground floor and were observed to contain appropriate furniture, bedding and linens.

BATHROOMS: There are 5 (five) bathrooms. 1 (one) is in the nurse's office and is used mainly for staff. An additional bathroom on the entry level is for shared client and staff use. 1 (one) private client bathroom and 1 (one) shared client bathroom are located on the lower level, and an additional 1 (one) client bathroom on the ground floor. All bathrooms were supplied with appropriate paper and hygiene products. Water temperature was measured in various client bathrooms and measured within the required range.

SURROUNDING GROUNDS: The backyard is fenced and includes various terraced landscaped areas, stairs and paved walkways/areas, including a patio and furniture appropriate for outdoor use as well as an outdoor fireplace, which Program Manager states is inoperable. No immediate hazards were observed outdoors.

STAFF/CLIENT FILE REVIEW: LPA reviewed 5 (five) staff records during today's visit for documents including, but not limited to: staff fingerprint background clearance, training records, health screening and TB test. LPA reviewed 5 (five) client records during the visit for documents including but not limited to: Admission Agreement, physician's report, and needs and service appraisals. All staff and client records reviewed were in compliance with Title 22 regulation at the time of the visit.

INFECTION CONTROL/DISASTER PREPAREDNESS: During today’s visit, the LPA reviewed the facility's infection control policy and disaster preparedness plan. Disaster drills are conducted monthly, with the last documented drill conducted on 04/23/2024. All documents reviewed were updated and in compliance.

INTERVIEWS: During today's visit, LPA interviewed 2 (two) clients and 2 (two) staff.

No citations issued. Exit interview conducted. Today’s report was reviewed and provided.