Facility Evaluation Report

Licensing Program Analysts (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPAs were greeted by Adela Santos, Administrator and explained the purpose of the visit.

The facility is licensed to serve clients between the ages of 18 to 59 and is approved for up to six (6) non-ambulatory clients. At time of visit the facility is serving mentally ill clients and census consisted of 60 clients.

Personal Rights postings were not observed in a common areas. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

The facility is located in a residential area on a busy street and consists of four (4) single-story buildings which accommodate twelve (12) client rooms each. Building B contains the kitchen/dining area and one (1) staff room. There is an additional building which contains the medication room, offices, conference room, two (2) storage rooms for maintenance and supplies, and a laundry room. All bedrooms contained the required furnishings, including beds, linens, dressers, and adequate lighting. Additional clean linens and towels were observed stored in the laundry room. The maintenance/storage area was observed to be locked. Cleaning supplies located in the laundry area were also observed to be locked and not accessible to clients. During the facility tour, LPA observed that restrooms located in Buildings B and C had water temperatures reading above 160°F, which exceeds the regulatory requirement of 105°F to 120°F.