Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza and LPM David Sicairos conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Mercedes Dominguez. Administrator Jessica Diaz arrived shortly after. There are three (3) ambulatory developmentally disabled clients in the home. The facility is licensed as an Adult Residential Facility (ARF) vendored by Harbor Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

· Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. Facility has submitted an Infection Control Plan.

· The facility is a single-story home located in a residential neighborhood that is licensed for four (4) ambulatory clients. It consists of 4 client bedrooms, living room, dining room, kitchen, 2 bathrooms, backyard patio area, and a detached garage.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.

· Water temperature was measured in bathroom #1 and bathroom #2 and measured between 112.2F - 116.7F which is within the required 105F - 120F.