Facility Evaluation Report

On 09/18/2025 at 9:35 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Direct Care Staff, Carol Anne Pacho, and explained the purpose of the visit. Administrator, Katelyn Salvador, came shortly after. Administrator certificate is current. The facility’s fire clearance was approved for ambulatory only.

LPA toured the facility including inside and out but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms for the clients and one bathroom. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature for clients is maintained at 73 degree Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 109.7 degree Fahrenheit. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/17/2024. First aid kit was observed to be complete. Emergency drill was last conducted on 06/09/2025.

At 10:12 AM, 3 of clients records were reviewed. At 10:31 AM, 4 staff records were reviewed and 4 of 4 have current first aid training and are associated to the facility. LPA reviewed 3 of 3 of clients’ medication. LPA reviewed client's P&I money with log. All records were observed to be complete and up to date.

No deficiencies cited. Exit interview was conducted with Administrator and a copy of this report were provided.