Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Florinda Aleman, Direct Support Professional (DSP) and explained the purpose of the visit. Shortly thereafter, another staff, Mercedes Bedolla, Direct Support Professional (DSP) arrived. One of the Administrators, Joy De La Cruz arrived at 11:30am and LPA discussed the purpose of the visit and was assisted. The facility is licensed to care for (4) Developmentally Disabled Adults, (2) ambulatory and (2) non-ambulatory with restricted health conditions, ages 18 through 59. All clients residing at this facility receive case management services provided by Harbor Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility does not have an Infection Control Plan in place. Infection control practices and Personal Protective Equipment (PPEs) were maintained, however. The staff stated that they use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (4) client bedrooms, (2) bathrooms, a living room, kitchen, dining area, backyard and attached garage. Currently, there are four (4) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, and toilet paper. LPA observed a broken faucet without the handle in bathroom #2 and approx. 6 inch hole in bathroom #1's wall. Exit doors are free of any obstruction and there are no pools or large bodies of water. LPA also observed old/broken chairs, broken window/door screens and unused paints in the side yard. Backyard was inspected and has a shaded area and sitting area. Attached garage was inspected. Kitchen was inspected and knives, sharps objects, cleaning supplies and toxic substances are locked under the kitchen sink cabinet and inaccessible to clients. However, LPA observed the laundry and other cleaning supplies which are stored in the upper cabinet in the laundry area was unlocked and accessible to clients. There is (1) fire extinguisher observed to be fully charged and last serviced on April 4, 2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured at 105.4 deg F in bathroom #1 and 105.9 deg F in bathroom #2 which are within the required 105 - 120 degrees Fahrenheit.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has not been added to the Plan. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid and will expire on 09/22/2024. Surety Bond is in effect and in force. The insurance will expire on 04/15/2026. Last Fire Drill was last conducted on 08/20/2023 and is not being conducted on a quarterly basis.