Facility Evaluation Report

Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility has a capacity of four (4). The facility is licensed to serve four (4) ambulatory, age 18-59 clients. Client census is two (2). LPA met staff, Andre Hearn upon arrival. Administrator, Pamela Bouligny joined the visit 30 minutes later. San Gabriel Pomona Regional Center provides case management service to client residing in this home. Facility annual fees are current. LPA discussed the purpose of today's visit. Administrator certificate is current and expiration date is 9/20/23.

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.

The facility is a single-story home located in a residential neighborhood within the city of Covina. It consisted of three (3) client’s bedrooms, one (1) bathroom, a kitchen, a dining room, a living room, an administration office, backyard with shaded area, and a detached garage with laundry area.

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. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility. Adequate linen and personal hygiene supply were observed. Bathrooms were clean and operational.