Facility Evaluation Report

On 09/20/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Marilee Cruz as the purpose of the visit was explained. The facility is licensed to serve 42 ambulatory mentally ill adults ages 18-59. Administrator provided with upcoming annual fees info and pin, surety bond is active.

The facility is located in a residential neighborhood and is a gated apartment complex with two buildings. Building 2330 consist of a single story. LPA observed 7 client bedrooms and one bathroom which contains 2 shower stalls and 2 stalls for toilets, the dining area, and 2 offices for visitors. Building 2340 consists of 2 stories. Each section has a restroom, a kitchen, laundry room, staff break room and storage room for cleaning supplies. 4 Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 3 staff records, 4 client records, 4 P&I ledgers, and 4 medication administration records. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted in August 2024 and is conducted quarterly, fire extinguishers observed throughout both buildings, carbon monoxide and smoke detectors are operational.

Exit interview conducted with Administrator Marilee Cruz, and a copy of this report was provided.