Facility Evaluation Report

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

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

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: Last Disaster Drill was conducted on 09/06/23. Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Carbon monoxide detector was tested and is operable. Fire extinguishers were observed. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Water temperature measured as follows: Room #1: 115.8*, Room #8: 113.0*, Room #9: 116.0*, Room #16: 118.1* and Room #18: 116.2*.

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 : Staff files are maintained at the Human Resources office which is on campus. LPA reviewed staff files for Staff #1 (S-1) and Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

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