Facility Evaluation Report

Licensing Program Analyst (LPA) Sanjay Vaid conducted the unannounced Annual Inspection visit using the Compliance and Regulatory Enforcement Tool. LPA met with Administrator Janet Deluna and the purpose of the visit was discussed. The following tool domains were completed:

Infection Control: LPA observed the facility has sufficient PPE supplies. Infection Control Plan is in place. The plan was collected and reviewed.

Physical Plant and Environmental Safety : The facility is licensed to serve 4 developmentally disabled adults ages 18 to 59 years old, of which (4) can be non-ambulatory. There are currently 4 clients who were placed by the San Gabriel Pomona Regional Center. Facility is located in a residential area and consist of a living room, kitchen, dining area, attached garage/laundry area, (4) client bedrooms, (1) and a half bathroom, office area and an office. The facility was inspected during the physical plant tour. No passageways or paths were obstructed.

Operational Requirements: Facility is operating within its approved clearance.

Staffing: The facility has a sufficient staffing in the facility. Facility is present during the nightshift.

Personnel Records-Training: Personal records centrally stored. LPA inspected four (4) staff files. All staff are background check cleared and associated with the facility. All the staff files have the required Title 22 documents. The administrators’ certificate expires 01/21/2026.

Client's Right - Information: No client in the facility required any postural support at the present time. Required postings observed.