Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA met with Maria DeCaballero, Direct Support Professional (DSP) and explained the purpose of the visit. Shortly after, Phillip Jordan, Acting Administrator arrived and assisted LPA. The facility is licensed to care for twenty two (22) Developmentally Disabled Adults ages 18 through 59, ambulatory only. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff clean and disinfect surfaces in the common areas on a regular basis. Staff are trained in the proper use of all required PPEs. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a 2 story home located in a residential neighborhood, has a total of (11) client bedrooms, with (4) on the ground floor and (7) on the upper floor. There are (5) bathrooms, with (3) on the upper floor and (2) on the lower floor. The facility also has a front porch with a shaded sitting area , office/storage supplies room , living room, dining area, kitchen, detached garage close to a laundry room, and backyard. Currently, there are (9) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Carbon monoxide operable, smoke detectors/ fire alarms are hard wired to the Fire Department of Pasadena. LPA observed the window screen in (2) bedrooms are broken. LPA also observed a gallon of cleaning product in the kitchen that was left out in the open in a preparation area and had no cap, staff immediately removed it. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and the area provides outdoor furniture and shade. Cleaning supplies, and toxic substances are locked in the storage cabinet along with medication. There are (4) fire extinguishers observed which were last serviced on 06/15/2025. There are no firearms or weapons stored at the facility. Facility does not have a video camera monitor system. Hot water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Operational Requirements: The Infection Control Plan has been added to the Plan of Operation. A fire clearance is in place. Surety Bond Insurance is in place. Emergency drills are conducted on a monthly basis and the last fire drill was last conducted on 06/19/202 5. *****REPORT CONTINUED ON LIC809-C****