Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Willie Rhodes (Caregiver) and explained the reason for the visit. LPA was later assisted by Administrator Jana West who assisted with the visit. The facility is licensed to serve 6 ambulatory clients ages 18-59. Facility currently has 4 ambulatory clients serviced by Frank D. Lanterman 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 area, kitchen, 3 bedrooms, 2 bathrooms, 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 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 was tested throughout the facility and was 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: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 10/17/2023.

Staffing : There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.

Personnel Records-Training : Staff files are maintained in the main office (offsite). LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: current First Aid/CPR/AED/CPI and sufficient on-going training. Administrators Jana West certificate expires 4/16/24.