Facility Evaluation Report

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced CM visit as a follow up to the appeal received on 04/21/25.

LPA revisited the following and made the appropriate corrections.

Physical Plant & Environmental Safety : The facility consists of a lobby area, ten (10) training/activity rooms {communication room, well-ness center, recreation, creative studio, computer lab, independent living, home economics/kitchen}, 10 restrooms, 2 offices, storages rooms, and 3 exits. The facility is clean and sanitary. LPA observed the outside yard in need of clearing grass and weeds. Disinfectants and cleaning solutions are properly stored and locked. The hot water temperature measured between 98.7-107.9 degrees F. which is not in regulatory range of 105.0 - 120.0 degrees F

Client Records - Incident Reports : LPA reviewed 4 Client files, and the files consist of the admission agreement, medical assessment with TB test result, consent forms, and 2 clients were missing current Individual Program Plan (IPP)

Two citations 82068.3(a) and 82088(e)(1) were reissued and reduced to type B deficiencies.

Citation 82087(a) was dismissed under appeal, Technical Advisory issued.

Exit interview conducted and copy of report, 809D page, technical advisory and appeal rights provided to program Manager Xenia Correon.