Facility Evaluation Report

Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Rachel Tran (Clinical Director) and Linda Leyva (Director of Licensure and Accreditation) and discussed the purpose of today’s visit.

This program is currently licensed for a capacity of 58 non-ambulatory clients between building 5 and building 8. This program operates Monday through Friday 9AM to 3PM.

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

Infection Control: Facility has an Infection Control Plan in place.

Physical Plant & Environment Safety: Carbon monoxide observed. Fire extinguishers observed throughout the premises (last serviced on 01/15/24). Water temperature measured between 107.0* to 113.0*. Filtered drinking water is available for clients. AED located near the gym (last serviced on 01/16/24). AED (label) indicates it is to be installed before 05/2028.

Operational Requirements: Staff are adhering to operational requirements. Fire clearance approved for a capacity of 58 non-ambulatory clients between building 5 and building 8.

Staffing : There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Refer to LIC 809C for the continuation of this report.