Facility Evaluation Report

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Masoumeh Ho - LVN and explained the reason for the visit. Administrator arrived 30 minutes later.

Facility is licensed to serve 4 clients age range 18 through 59, of which 4 may be non-ambulatory and/or bedridden. The single home is located in a residential facility and consist of 4 client bedrooms, 3 bathrooms, a kitchen, a living room, a dining room, an office, a laundry area, a back yard, a front yard, and a detach garage.

LPA Flores conducted a tour of the facility with Masoumeh Ho - LVN and observed the following:

Facility is in good repair inside and outside. No large bodies of water were observed. Smoke/Carbon Monoxide detectors were tested and in working condition. Living room and dining room have a fireplace glass covered. Kitchen area is clean. Sharps and cleaning supplies were observed locked under the sink. Facility has sufficient food supplies for at lest 2 days of perishables and 7 days of non-perishables. Medication cabinets were observed locked. Each clients bedroom is in good repair, with sufficient lighting, required furniture and bedding. Bathrooms were observed in good repair and water temperature was tested between 111.1 and 115.5 which is within the required water temperature. Back yard has a shaded sitting area. Fire extinguisher was observed and last inspected on 6/1/22.

LPA Flores reviewed medication and files for 4 residents and 5 staff files. Administrator certificate was observed for Andres Rojas #6058196735 exp. date: 9/15/23. Emergency disaster plan version (LIC 610D 10/03) which is not the required current version LIC 610D 12/21. LPA conducted interviews with clients and staff.

Deficiency was noted on LIC 809D per Title 22 regulations. Exit interview was conducted with Andres Rojas Administrator and a copy of report, LIC 809D, and appeal rights were provided.