Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Magdalena “Maggie” Estrada (Administrator) and explained the reason for the visit. The facility is licensed to serve 6 ambulatory clients ages 18-59. Facility currently has 5 ambulatory clients serviced by South Central Los Angeles Regional Center.

The facility is a single-story home located in a residential area in Pasadena, Ca. A tour of the facility includes: living room, dining room, den, kitchen, laundry area, cleaning closet, linen closet, 2 bathrooms, 4 bedrooms, detached garage, front yard and back yard.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.

Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature in both client bathrooms was tested and were within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.

Operational Requirements: The facility maintains an approved fire clearance and conduct regular fire/earthquake drills. Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use, however, there was no shaded area to meet the requirement details will be cited on the 809-D.