Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Esthella Villareal and Sherry Bibawy, program supervisor and program managers for the facility, and explained the purpose of the visit.

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.

· Facility has an infection control plan on file.

· The facility is licensed to serve fifteen (15) non-ambulatory clients in the building between the ages of eighteen (18) and fifty-nine (59). It is located in a business area and consists of the following: Rest Room, 3 Administrative offices, 1 female and 1 all gender bathrooms, Musical room, Computer room, Art room, Fitness room, Resource / Library area, Staff/ Client Locker area, and fully equipped kitchen. The bathrooms were observed to be clean and operational. The water temperature was tested in both bathrooms and measured between 117.5 – 118.2 degrees Fahrenheit, which is within the required 105-120 degrees Fahrenheit range.