Facility Evaluation Report

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Rosario Navarrete Program Manager and explained the reason for the visit. Administrator arrived shortly after.

This facility is licensed to served 38 ambulatory only mentally disabled adults ages 18-59 years old. The facility is located inside a Hospital's property and it is a two story building which is compose of several client bedrooms, offices, a commercial kitchen, a dining room area, an activity/rest area, 9 client bathrooms, 1 staff bathroom, a medication room.

The following CARE tool domains were reviewed during this visit:

Infection Control: Facility maintains an infection control plan and will email a copy to the department. Hand sanitizing and infection prevention were observed at the facility. A responsible person was available at the facility.

Physical Plant & Environmental Safety: LPA toured the facility with Rosario Navarrete and observed the facility is in good repair indoors and outdoors. Activity room/dining room has sufficient seating area, it's clean and in good repair. Each client bedroom has sufficient lighting, the required furniture and bedding supplies. Nine bathrooms were observed clean and in good repair. Water temperature was tested between 92.1-128.1 degrees F., which is not within the required 105-120 degrees F. Carbon Monoxide/Smoke detectors were observed in each client room and a fire sprinkler system was observed throughout the building. Laundry area was observed clean and in good repair, detergent is provided to the clients as needed. Kitchen was observed clean, in good repair. Passageways and exit areas were observed free of obstructions. No large bodies of water were observed. First aid kit and fire extinguishers were observed which were last checked on 10/15/24 (CONTINUED ON LIC 809C)