Facility Evaluation Report

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

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

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

Operational Requirements: Staff are adhering to operational requirements. This facility has a fire clearance for (5) ambulatory clients.

Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detectors observed and tested. Fire extinguishers were last serviced 01/15/25 (observed throughout this facility). The fire extinguishers are also checked by staff on a monthly basis (last checked on 10/01/25). Last fire drill was conducted on 09/15/25. Last emergency disaster drill was conducted on 09/30/25. Hot water supply measured at 105.4*. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients..

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.

Personnel Records-Training : LPA reviewed staff files for Staff #1 (S-1) through Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis clearance.

Client Rights-Information: Client rights observed in client files. Client rights were observed to be posted as well.

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