Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced Annual inspection on 9/4/25. LPA met with Licensee/Administrator Joycelyn Lamauig and explained the purpose of the visit. The facility is licensed to serve (6) ambulatory, mentally disordered clients 18-59 years old. There are currently (4) clients residing at the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today.

Staff are continuing to follow their Infection Control Plan and using appropriate hand hygiene and wearing gloves when deemed necessary. Staff are adhering to operational requirements. The facility is a single-story home with three (3) client bedrooms, two (2) staff rooms, two (2) bathrooms, kitchen, dining room, living room, and attached garage. Bedroom have required furniture and storage space. There are no pools or bodies of water on the premises. Knives and cleaning solutions are locked and inaccessible to clients. The water temperature was measured within the required range of 105-120 degrees F. Sufficient food supplies were observed. LPA reviewed two personnel files. The Administrator's certificate expired on 5/17/25. LPA verified that the renewal documents were received on 5/9/25 and is pending to be reviewed. Administrator has the HIV & TB certificates issued on 4/22/25. Both staff have current First Aid & CPR certification. LPA reviewed all four (4) Client files and medications. The files have the required documentation and staff are administering the medications as prescribed. The facility uses the Medication Administration Record (MAR) log to document medications given. There are no clients with a restricted health condition or using any postural support. LPA issued a deficiency for not having the Emergency Disaster Plan in place. A technical violation was issued for emergency/disaster drill as it was not being conducted at least quarterly.

The deficiency is issued on the LIC809D page. An exit interview was held. A copy of this report and appeal rights were provided to the administrator.