Facility Evaluation Report

Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA was allowed entry by Rebecca Viloria. Facility Administrator, Manuelita Reyes, arrived at approximately 8:45 AM to assist with this inspection. LPA explained the purpose of today's visit.

The facility is licensed for mentally ill clients ages 18-59. The fire clearance is approved for (6) ambulatory clients.

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

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator all (5) clients have COVID-19 vaccines including boosters. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements.

Operational Requirements: The fire clearance is approved for (6) ambulatory clients. Last Fire Drill and Earthquake Drill: 01/20/2023. Per Facility Administrator, these drills are completed every (6) months. Facility Administrator is adhering to operational requirements.

Refer to LIC 809C for the continuation of this report.