Routine inspection·August 22, 2024

Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Liam Larson who greeted LPA and assisted with the tour of the facility. At 10:00 AM the Administrator Rose Nakadaira arrived at the facility and she was informed of the purpose of the visit. Physical Plant: LPA observed there are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms: they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The hot water temperature was tested throughout the facility which was within regulation 104-124 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins,and other dangerous items were kept inaccessible to clients in care. There was a designated place for client/staff files . Overall, the facility appeared to be clean, in good repair, and operating in safe conditions. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. LPA also observed emergency food supply and water. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s) which appeared to be administered as prescribed by their physicians. LPA also reviewed Three (3) staff files for First Aid/CPR certification, annual training's, health screenings and the files reviewed were not complete/current. Based on LPA's observations a citation was issued for not having the staff files current. An exit interview was conducted, and this report was discussed and provided to Administrator Rose Nakadaira at the conclusion of the visit.