Facility Evaluation Report

Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility is licensed to serve four (4) non-ambulatory, Developmentally Disabled adults from 18 to 59 years old. The regional center is San Gabriel/Pomona Regional Center. The annual fee is paid. LPA discussed with administrator, April Villondo, over the phone and with House manager in person regarding the purpose of today's visit and the inspection.

During the visit, the following domain of the new inspection tool was used: infection control domain;

a tour of the facility conducted; food supply was reviewed; and medications were reviewed.

LPA toured the facility. The facility is a single story house located in a residential area. It consist of a living room/office, kitchen, dining room, activity room, four (4) client bedrooms, one (1) full bathroom, one (1) 1/2 bathrooms, nurse/medication station, laundry/utility room and attached garage. A shaded area with chairs was provided in the rear. Bathrooms are operational. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Each client's bedrooms has a bed, dresser and closet space available. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Dual detector (smoke detector combined with carbon monoxide detector) are operable. Hot water temperature is measured at 110.2 degrees Fahrenheit. Medications are centrally stored and locked. Medications were properly logged and current. Fire extinguishers are fully charged and the last service is 10/1/2021. Hazardous items are locked and inaccessible to clients. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils were stored. Fire drill is conducted on 7/2/21. There is a ramp to enter the home and a ramp in the backyard to access the seating area.

No deficiencies were observed in violation of California code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed and provided to house manager, whose signature on this form confirm receipt of these documents.