Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the Compliance and Regulatory Enforcement (CARE) tools. LPA was met by Jennifer Tapia, Direct Care Staff and explained the purpose of the visit. Clarissa Basto, Medication Supervisor and Carmelo Jimenez, Maintenance assisted LPA with the physical plant tour. Shortly after, Ruby Garcia Administrator and assisted LPA . The facility is licensed to care for 136 clients ages 18-59, ambulatory only. Facility has approved hospice waiver for (5) residents.

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Staff are adhering to infection control requirements. Staff use a pair of gloves for each client when administering first aid.

Physical Plant/Environment Safety: The facility is located in a residential neighborhood, has 2 floors and a basement. The 1st floor consists of 29 client rooms, dining room, kitchen, laundry room, food storage room, housekeeping supply room, medication room, main office and bookkeeping office. The 2nd floor consists of 41 client rooms, employee lounge, activity and TV rooms, and activity closet. Currently, there are (79) clients living in the facility. The interior and exterior physical plant was inspected. Random client bedrooms were toured and wach bedroom has a bed, linen, dresser, night stand and sufficient closet space. Bathrooms contained hygiene supplies, however LPA observed molds in the ceilings and walls of some bathrooms on the 1st and 2nd floors. Additionally, the paint on the ceilings in several bathrooms is peeling. There are several fire extinguishers observed to be fully charged and were last serviced on 06/17/2025. There are cameras observed in the common areas Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and there are covered areas equipped with chairs and tabled for clients. There are no pools or bodies of water on the premises. There are no firearms or weapons stored at the facility. Random resident bathrooms were inspected and hot water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Operational Requirements: Infection Control Plan has been developed and included in the Plan of Operation. A fire clearance is in place. The outdoor activity area provide a shaded area, comfortable and furnished for outdoor use. Liability Insurance policy is valid and will expire on 05/08/2026. Surety Bond is in place. Last Fire Drill was conducted on 05/16/2025.