Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Julia Elias, Medication Technician (Med Tech) supervisor for the facility, and explained the purpose of the visit. Administrator Tony Olmos arrived shortly thereafter. There are one-hundred and thirty-six (136) clients residing within the facility.

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.

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has a completed infection control plan.

· The facility is a two-story building located in a residential neighborhood that is licensed for a capacity of one-hundred and seventy-five (175) ambulatory and ten (10) non-ambulatory clients between the ages of eighteen (18) through fifty-nine (59). It consists of ninety-three (93) client bedrooms, a kitchen, a dining room, two (2) TV rooms, multiple storage rooms, multiple washing machine rooms, and client bathrooms in all the bedrooms, and all the eleven (11) rooms which LPA toured measured between the required ranged of 105 Degrees F – 120 Degrees F. Knives along with the chemicals and cleaning supplies are kept locked and inaccessible to clients. A shaded outdoor area was available for clients in the backyard of the facility.