Facility Evaluation Report

Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena conducted an unannounced Case Management – Other visit, for the purposes of conducting a comprehensive annual. The LPAs met with staff and explained the reason for the visit. Administrator Pacita Serrano arrived at approximately 2:00 p.m.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed at 10:05 a.m. The facility has a sufficient supply of non-perishable and perishable food items. During today’s visit, the LPAs found expired food. The LPAs discovered the following: bread expired 7/27/2022, two packages of hot dog buns expired 7/24/2022, two boxes of muffin mix expired 6/2021, salad dressing that expired 2021. In addition, salad dressing was stored open in the cabinet, and the LPAs asked staff to discard these items. The LPAs found lighters and matches accessible in a drawer at 10:25 a.m. At 10:27 a.m., the LPAs found unsecured medication in the refrigerator. Staff stated it was their medication. Cleaning supplies and disinfectants are stored inaccessible. Knives are stored in a locked cabinet in the kitchen. At 10:20 a.m., the hot water temperature in the kitchen measured at 108.7 degrees Fahrenheit.

Restrooms: Fixtures in the client restrooms were in operating condition. The shower in the shared client bathroom in the hallway was unkempt. The non-skid mat observed in the shower appeared to be unclean. At 10:37 a.m., the hot water in the common hallway bathroom measured at 108.5 degrees Fahrenheit.

Bedrooms: The LPAs toured the client rooms. Furniture was observed in disrepair in Room #2, Room #3, Room #4 and Room #6. A linen closet was located outside of the rooms, which stocked extra linens and towels.