Facility Evaluation Report

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Marilyn Sabio and the purpose of the visit was discussed. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has a plan of operation and infection control plan in place. Infection control practices and Personal Protective Equipment (PPEs) were observed. Staff are adhering to infection control requirements.

Operational Requirements: The facility is licensed to care for up to (12) Adults, ages 18 through 59, ambulatory only. Fire clearance approves Six (6) clients in 15027 building and six (6) clients in house 15031. Sufficient space for activities observed. Last Fire Drill was conducted on 2/3/2024. Signal System Inoperable.

Physical Plant/Environment Safety: The facility contains 2 Houses, House #1 is a structure located in the back (15027) consists of (4) clients bedrooms, (2) full bathrooms, kitchen area which is also utilized as a staff room, living room and a backyard. House #2 located in front (15031) consists of (3) client bedrooms, (1) staff room, 2 full bathrooms, living room, dining area, kitchen, laundry area, office area front porch, patio and detached garage for storage. Currently, there are ten (10) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector and required furniture, linen, linen, and sufficient closet space. Bathrooms contained hygiene supplies including liquid soap, paper towels, and toilet paper. LPA observed all windows to be in good repair. Exit doors are free of obstruction and there are no pools or large bodies of water. Backyard was inspected and observed. Detached garage was toured. The garage was locked and inaccessible to clients in care. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. Three (3) fire extinguishers last inspected April 2024. Smoke alarms and carbon monoxide were tested and operational. There are no firearms or weapons stored at the facility. Water temperature readings measured at 133 and 127 in client bathrooms, which is not in line with title 22 regulation.