Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Mylene Bumanlag and Jennifer Kim, Administrator and Licensee for the facility, and explained the purpose of the visit.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

· Facility has an infection control plan on file.

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) clients between the ages of eighteen (18) through fifty-nine (59), two (2) of whom may be non-ambulatory. It consists of four (4) client bedrooms, a kitchen that also contains the facility washer and dryer, a dining room, a living room, two (2) client bathrooms of which Restroom #1 had a hot water temperature reading measured at 107.2 Degrees Fahrenheit, and Restroom #2 had a hot water temperature reading at 106.5 Degrees Fahrenheit, and a back yard with a locked shed and staff area. Knives are kept locked in a cabinet in the kitchen of the facility, and the chemicals and cleaning supplies are kept locked in the laundry room of the facility. A shaded outdoor area was available for clients in the backyard of the facility.