Facility Evaluation Report

On 09/21/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual

Inspection. LPA introduced self, stated the purpose of the visit, and met with Administrator Jessica Delgadillo. LPA toured facility with Administrator. One client was present during the inspection in the client's room.

The tour started in the common areas into the kitchen to the client’s rooms. The facility was observed to be at a comfortable temperature at 72 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside.

Fire extinguisher was observed with a service date of: 08/10/23. Fire drill last completed on 0916/23. Cleaning chemicals was observed stored and locked in the garage cabinet. Medications were checked and observed kept locked in kitchen closet. Clients’ MARS was reviewed. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -10 degrees F and refrigerator temperature was maintained at 30 degrees F.

Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and

adequate lighting. All bathrooms are toured. Hot water temperature was tested 109 degrees F. in bathroom 1 and range between 111.7 and 111.9 degrees F. in master bathroom.

Outside of facility toured. Side gate was self-closing and self-latching. All clients’ file reviewed to have update Emergency contacts, Admission agreement, IPP, and physician report. LPA reviewed three staff files to have current First Aid/CPR, Personnel Record, Criminal record Statement, and Health Screening. Carbon monoxide and smoke detectors were tested and observed to be operational.