Facility Evaluation Report

Licensing Program Analysts (LPA) Luis Mora conducted an announced Pre-Licensing visit. LPA met with Administrator Jasfer Cruz and explained the reason for the visit. A change of location application was submitted to Community Care Licensing Department (CCLD) for an Adult Residential Facility to serve 2 ambulatory and 2 non-ambulatory clients in the age range of 18 through 59.

A tour of the single-story facility included: living room, kitchen, dining area, staff office, 4 client bedrooms, 2 client bathrooms, attached garage, front yard, and backyard. LPA Mora conducted the tour with Jasfer Cruz and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps are kept locked in a kitchen cabinet. The First Aid kit is kept locked in the medication closet. The First Aid kit was fully stocked with all required items including a current manual. Cleaning and chemical solutions are kept locked in a bathroom cabinet. Dining and living room have sufficient lighting and sitting area. Medications are centrally stored in a locked hallway closet. All bedrooms have all required furniture, lighting, and bedding. There are clean linen and towels in each room closet. All bathrooms were observed with non-skid material. Water temperature was tested at 116.9 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the dining area, and it is fully charged. Smoke detectors combined with carbon monoxides were observed throughout the facility and in each room and were operable during the visit. Client and staff files will be kept locked in the medication closet. The front yard and backyard are clean, and there is a shaded sitting area in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

No outstanding or pending items were observed by LPAs requiring additional pre-licensing visits. LPAs will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.

Exit interview conducted and a copy of this report was provided to the Administrator.