Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 09/05/2023 at 8:26 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) and is vendored by San Gabriel/Pomona Regional Center. The facility is licensed to serve five (5) developmentally disabled clients ages 18 and above; of which five (5) may be bedridden. During today’s visit, LPA Ramirez observed four (4) staff members providing direct care and supervision to clients in care. LPA Ramirez requested and obtained copies of Personnel Report, and Client Roster.

LPA OBSERVATIONS: Tour began at 9:07 am and was led by LPA Ramirez. The facility is a single-story home that contains five (5) bedrooms fully equipped with mechanical lifts, two (2) bathrooms of which one (1) is equipped with a mechanical lift, living room, TV room, kitchen, dining room, laundry room, backyard shaded patio area, and attached garage. LPA Ramirez observed one (1) Registered Nurse (RN), two (2) Licensed Vocational Nurses (LVN), and one (1) Direct Support Personnel (DSP) during visit. Fully charged fire extinguishers were observed throughout the facility.

Front Yard: Was clean and well maintained. No hazards were observed. Passageways are free of any obstructions.