Facility Evaluation Report

Licensing Program Analyst (LPA) Tyler Reyes conducted the required annual inspection. LPA arrived unannounced and met with Pedro Burgos (Administrator) and explained the purpose of today’s visit. The facility is licensed to serve 16 Ambulatory clients. Note: this is a short-term crisis residential program.

This is a 2-story facility located in an industrial area in Downey, Ca. A tour of the facility includes: First Floor: 2 client bedrooms, 2 restrooms, 1 shower room, 1 staff restroom, kitchen, patio, dining room, group activity room, clinician station, nurse station/medication room, group room (intake room), janitor closet (cleaning supplies), storage room (with hygiene products), laundry room, hygiene intake room with restroom, administrators office, elevator maintenance room, and electrical room. Second floor: 6 client bedrooms, 3 shower rooms, 3 restrooms, janitor room, laundry room, linen storage room, family/group room, medical record room, staff break room, and staff restroom.

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 gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.

Physical Plant & Environment Safety: LPA toured facility and observed 6 clients’ bedrooms, each room had the required furniture for comfort and safety and had sufficient lighting. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available and stored in a storage room. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured/locked area and inaccessible to clients. The last Fire/Emergency Drill was conducted on 5/8/24. Smoke detectors and carbon monoxide detectors are operable and in compliance, there is an emergency sprinkler system throughout the facility. The fire extinguishers were observed and are fully charged.