Facility Evaluation Report

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit using the CARE tool at the facility. LPA met with Jennifer Tayag Direct Support Staff (DSP) and explained the reason for the visit.

The facility is licensed to serve (6) six non-ambulatory clients ages 18-59. Developmentally disabled only. The facility is located in a residential neighborhood and it consist of (4) four client rooms, (2) two client bathrooms, a kitchen, a dining room, a living room, a laundry room, a front yard, a back yard, and an attached garage inaccessible to the clients.

LPA Flores conducted a tour of the facility with Jennifer Tayag DSP and observed the following:

Living room and dining room are clean and have seating space. Kitchen was observed, refrigerator and freezer has sufficient food for at least (2) days worth of perishables and (7) days of non-perishables. A small medication refrigerator was lock. Cleaning solution was observed under the sink cabinet and unlock during the visit. Medication and sharps cabinet located to the left of the kitchen was unlock during the visit. (4) client bedrooms were observed, each with sufficient lighting, bedding supplies, and furniture. Client #1 has a half bed rail in bed and an exemption request was submitted and approved on 12/1/20 by the department. Bedroom #4 (BR4) was observed with blanket and towel by the exit door per DSP water had come in due to the rain, mildew smell was noticed and water damage was observed in the lower corner next to the hinges of the door. (2) bathrooms were observed in working condition and water temperature was measured as follow: temperature in bathroom #1 tested at 107.4 degrees F., and in bathroom #2 tested at 109.7 degrees F. which is within the required 105-120 degrees F. Interlace Smoke/Carbon monoxide detectors were tested and in working condition. The backyard has a covered sitting area and a fenced/covered pool which is out of order. LPA Flores reviewed medication, files and P&I money for (4) clients. LPA reviewed files for (5) staff. Last fire drill was conducted on 12/10/22. Administrator certificate #6022165735 exp. date: 12/22/24 was observed for Margie Canlobo. Emergency disaster plan LIC 610D 10/03 was reviewed.

Deficiencies were noted on LIC 809D under Title 22 Regulations Division 6 Chapter 1.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.