Facility Evaluation Report

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Program Director Reyna Zavala.

According to the facility’s license, the facility has a maximum capacity of eighty (80) clients, of whom twenty-five (25) may be non-ambulatory. During today’s inspection, there were a total of fifty-seven (57) clients present and twenty three (23) staff present. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by Program Director, toured the interior and exterior of the facility. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Doors, windows and screens, toilets were in working order. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant: kitchen sink was 111.5 F, bathroom and restroom was at 109 F. Kitchen sink had a minor leak, Program Director provided LPA with a involve for services scheduled for 1/16/25. There were no sharp objects or toxic chemicals/poisons accessible to clients.

No pools or bodies of water on the property. Per the program director, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed staff and client records, all of which contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with the Program Director Reyna Zavala, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit