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 Massoumeh Ho - LVN and explained the reason for the visit.

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 an attach garage.

The following CARE tool domains were reviewed during this visit:

Infection Control: Facility maintains an infection control plan. 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 Massoumeh Ho and observed the facility is in good repair indoors and outdoors. Living room and dining room have a fireplace which are covered. Each client bedroom has sufficient lighting, the required furniture and bedding supplies. Two (2) bathrooms were observed during this visit as the third bathroom was under repairs at the time of the visit. Bathrooms were observed clean and in good repair. Water temperature was tested in both bathrooms at 115.3 degrees F., which is within the required 105-120 degrees F. Carbon Monoxide/Smoke detectors were tested and are in working condition. Laundry area is located next to the kitchen. The backyard offer shaded seating area for the clients. Garage is not accessible to the clients. Passageways and exit areas were observed free of obstructions. No large bodies of water were observed. First aid kit and fire extinguishers were observed. (CONTINUED ON LIC 809C)