Facility Evaluation Report

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection. The facility is licensed as Adult Residential Facility to serve for ages 18 to 59 years old, four (4) ambulatory clients, of which one (1) maybe non-ambulatory. Client census is zero (0). Annual fee is current. LPA met Gemma Rodriguez, Administrator, who assisted with the visit. LPA discussed with Administrator about the purpose of today's visit.

During the visit, the following domain of the new inspection tool was used: infection control domain and staff interview; Besides, staff file was reviewed; a tour of the facility was conducted; and food supply was reviewed. Since client census was zero, LPA did not conduct client interview, medication review and client file review.

LPA toured the facility inside and outside. The home is located in a residential neighborhood within the city of Covina and is a one story building which consists of four (4) client bedrooms, two (2) bathrooms, kitchen, dining area near the kitchen, living room with a TV, laundry room, and backyard with a patio. The kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. All burners and stove tops were in working condition. Clients’ bedrooms have beds, dressers, chairs and closet space available. Adequate linen and personal hygiene supply are observed. Bathrooms are clean and operational.

LPA also inspected facility common areas including the kitchen, living room, and dining room. Administrator tested the smoke detectors and carbon monoxide detectors were operable. Fire extinguisher was fully charged. Comfortable temperature of 73 degree Fahrenheit for clients was maintained. Hot water temperature measured at 109.5 degrees Fahrenheit. Client beds were in good condition and had appropriate linens. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility. (-continued in LIC 809 C-)