Routine inspection·March 28, 2024

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by DSP Diana Valencia. Administrator Robert James Tramison joined the inspection approximately ten minutes after LPA's arrival. The facility is a one-story home with six bedrooms, three bathrooms, kitchen, dining room, living room, backyard and attached 2-car garage. Facility appears clean, safe and sanitary. LPA noted residents were eating lunch at the time of inspection. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Two resident rooms have recliners instead of beds in order to satisfy the preference of the residents. Facility has extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 106.3, 106.8 and 107.3 degrees Fahrenheit in the three bathrooms. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was last serviced in February of 2023. AD stated the facility is getting the extinguishers and fire blanket serviced within the same week of the inspection. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen, hallway and the garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a closet near the garage. The backyard has four sitting/lounging areas. AD stated some of the umbrellas are in storage due to recent high winds. Exit gates are unlocked and self latching. LPA observed exit gates to be unobstructed. LPA reviewed two client files and medication as well as three staff files. During record review, LPA noted the facility's Infection Control Plan is written on an LIC9283 for Day Programs. LPA advised AD to transfer information on LIC9283 to LIC9282. Facility was unable to produce proof of drills completed during the inspection. A deficiency was issued on this day. Based on today's inspection one deficiency was issued. An exit interview was conducted and a copy of this report, appeal rights and LIC9282 was provided to the facility.