Facility Evaluation Report

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

This facility consists of four (4) single-story buildings which accommodates 12 double-occupancy rooms each. There is also building which consists of the medication room, offices, activities room, main storage room and laundry room and a kitchen with dining area.

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: The fire clearance is approved for (78) ambulatory and (6) non-ambulatory clients. Last Disaster Drill was conducted on 05/31/23. Staff are adhering to operational requirements.

Staffing : There is sufficient staffing at the facility. Administrator Certificate for Adela Santos (expired 07/14/22). Per Administrator, documentation (which includes T.B and HIV training) was sent to CDSS prior to expiration date for the Administrator Certificate renewal. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

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