Routine inspection·July 22, 2024

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required 1 yr. inspection to this facility and was welcome by Administrator/Licensee Fayretta Johnson. One resident had already left to attend their day program at the time of the visit. There are 4 clients in the facility. LPA toured the facility on 7/22/2024 at 11:15 AM with administrator/licensee Fayretta Johnson, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/30/2024 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot water temperature measured between 105 degrees F and 108.5 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 client’s bathroom while touring facility on 7/22/2024. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the facility garage. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads. A review of four clients and a sample review of two staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 12:15 PM on 7/22/2024 and learned that 4 of 4 clients have an updated reappraisal/needs & care plan and physician’s report. LPA conducted a sample review of staff records on 7/22/2024 at 1:00 and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Facility has proof of Direct care staff training. LPA was presented with proof of 1 st Aid certification for staff records that were reviewed. Continue LIC 809-C P&I's are kept in a locked filed cabinet in the facility office room; facility responsible for all client’s P&I and money; facility had P& I and ledgers available during the visit. P& I money not comingled, and ledgers are current on 7/22/2024. Medications were centrally stored in a locked closet cabinet in the kitchen of facility on 7/22/2024. LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions on 7/22/2024 at 1:50 PM. Centrally Stored Medication Records (CSMR) on 7/22/2024 were found to be current. Fayetta Johnson's Administrator Certificate # 6018327740 expired on 7/19/2024, LPA observed proof of pending certificate. LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time. Disaster Drills have been conducted often to allow all staff to participate with the last one being conducted on 7/6/2024. There were no deficiencies cited at this time. LPA is requesting the following documents be submitted to CCL by 8/5/2024: LIC 400 Affidavit Regarding Resident Cash Resources LIC 402 Surety Bond (if applicable) LIC 610 Emergency Disaster Plan (if changed) LIC 9020 Register of Facility Resident’s Copy of Current Liability Insurance