Facility Evaluation Report

Licensing Program Analyst (LPA) Gabriela Castro conducted an announced Annual Inspection. LPA met with Rachel Tran and explained the purpose of today's visit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools during today's inspection and observed the following:

Infection control practices were observed to be implemented throughout the facility.

The facility is operating within its licensed capacity. Staff are adhering to operational requirements. The facility has an approved fire clearance for 46 non-ambulatory clients and 3 bedridden clients.

LPA toured Buildings 6, 7, and 8. Building 8 is utilized for physical therapy services. In Building 6, LPA inspected four client bedrooms. In Building 7, LPA inspected three client bedrooms. All rooms contained the required furnishings and appeared clean and in good repair. Building 8, LPA observed clients actively participating in physical therapy sessions. Smoke alarms and carbon monoxide detectors were observed throughout the facility. Fire extinguishers were serviced within the required timeframe and were observed throughout the facility. Hot water temperatures were tested and measured within the required regulatory range. Knives, cleaning solutions, disinfectants, and other hazardous items were locked and inaccessible to clients. Adequate linens, towels, and incontinence supplies were observed. No bodies of water or other environmental hazards were observed. The facility offers an array of structured activities designed to promote client engagement, socialization, physical well-being, and cognitive stimulation. Staff reported that community outings are offered on a regular basis, providing clients with opportunities to participate in recreational events appropriate to their interests and abilities. (continued on 809C)