Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Caregiver - Ana Mendoza, and explained the purpose for today’s visit. The facility is licensed to serve 3 Ambulatory Developmentally Disabled Adults Ages 18-59 years old. Clients at facility are serviced through Harbor Regional Center.

The facility is a single-story home located in a residential area in Bellflower, Ca. A tour of the facility includes: Living Room, Dining Area, Kitchen, 3 client bedrooms, 2 client bathrooms (one bath in client bedroom), storage closet for files, storage cabinets for hygiene/linens, attached garage, front/back yard.

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

Infection Control: Facility maintains the required Infection Control Plan maintained at the facility.

Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept locked and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Bells on doors were tested and operable.

Operational Requirement s: Facility has an activity area furnished for outdoor use.

Staffing & Personnel Records-Training : There appears to be sufficient staffing at all times. Staff files are maintained in a secure location. LPA reviewed 3 staff files during today’s visit, each contained the following: Criminal Background Clearance, Health Screening, TB, First-Aid/CPR/AED and sufficient on-going training. Johnette Bellosillo maintains a valid certificate that expires on 1/23/27. (Continued on LIC809-C)