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. Linda Leyva arrived at approximately 8:50 A.M..

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 (46) non-ambulatory clients and (3) bedridden 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 08/04/25. Last emergency disaster drill was conducted on 09/30/25. Hot water supply measured between 113.5* and 117.5*. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Linens, towels and incontinence supplies observed.

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.

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