Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera along with Jade Xu, conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Ian Baker (Administrator at sister facility), and Monique Jordan (back up Administrator) and Cheryl Jackson who later assisted with the visit, LPA explained the purpose for the visit. The facility is licensed to serve 60 Adults ages 18 and above.

This is a single- story facility located in Pasadena, Ca. A tour of the facility includes: a bakery with walk-in freezer and walk in oven, 3 storage closets, 4 client restrooms, 1 staff restroom, 2 staff office rooms, isolation room, participant “store”, activity room, craft room and outdoor shaded activity area.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.

Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance, there is an emergency sprinkler system throughout the facility. The fire extinguishers were observed and are fully charged. No bodies of water were observed at the facility. The hot water temperature was tested throughout the facility restrooms and measured within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, poisons and hazardous items are stored in a secured/locked storage closet and inaccessible to clients. There is a shaded rest area provided for the clients. Clients are provided with a non-contaminating water container that is readily available for indoor and outdoor use. The facility appears to be clean safe and sanitary. The hand washing station in main activity room was observed to have a leak, details will be provided on the 809D page.