Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Annual Continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Maria Liliosa Franco, Direct Care Staff and Tessie Bato, Direct Care Staff and explained the purpose of the visit. At 2:20pm, Administrator Marycel Campos arrived and assisted LPA with the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant/Environment Safety: The facility is located in a residential neighborhood and the home has 2 floors, ground floor and the main floor. Main floor is the only area that is licensed which contains a total of (7) client bedrooms, (1) staff bedroom, (4) bathrooms, a living room, office area, kitchen, dining area, front patio and backyard with shaded area. There is a storage room in the ground floor where additional supplies are stored. The garage in the ground floor was converted into an additional live in unit by staff and is inaccessible to clients. The ground floor has separate entrances/exits. Currently, there are twelve (12) clients living in the facility. The interior and exterior physical plant was inspected. Client rooms were toured and have the required furnishings. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard has a shaded area and sitting area. Laundry area is in the ground floor which is kept locked when not in use. There are (5) fire extinguishers all over the home which was just serviced on 07/24/2024. There is a fire alarm pull station in the hallway and the home is equipped with a centralized sprinkler system. The home has a central heating system and individual AC units inside each client bedroom. The home was inspected by the Pasadena Fire Dept. on 4/12/2024 and did not pass due to lack of fire alarm protective piece in the electrical panel next to the dining room. Re-inspection by the Fire Dept. was scheduled after 5/10/2024. There are no cameras, firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Readings were 109.5 deg F in bathroom #1, 108.3 deg. F in bathroom #2 and 110.5 deg F in bathroom #3.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Surety Bond in the amount of $10000 is valid and expires on 7/19/2027. Last fire drill was conducted on 10/15/2023 and earthquake drill was conducted on 8/25/2023.

Staffing: A total of none (9) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.