Facility Evaluation Report

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced annual inspection visit. LPA met with Jeam Tan Assistant Administrator and Administrator Shahbaz Baig who assisted with the visit. LPA explained the purpose of today's visit.

This is a one-story Adult Residential Facility (ARF) facility consisting of 16 shared client bedrooms, 9 bathrooms, kitchen, dining room, activities room, laundry room, locked medication cabinet in kitchen, staff office and outdoor shaded area. This facility is licensed for a capacity of 32 clients and today's census was 31.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. An Infection Control Plan at the facility.

Physical Plant & Environment Safety: The facility is free of debris/hazards. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 126.3 -143.7 degrees F which is not within required range of 105.0 -120.0 F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are inaccessible to clients. The last Fire/Emergency Drill was 03/09/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and recently inspected.

Operational Requirements: Facility is complying.

Staffing : There appears to be sufficient staffing in the facility. CPR/First aid certificates are on file. Administrator Assistant Administrator Certificate expires on 02/08/2025. Last fire drill was on 03/09/23

Personnel Records-Training : Staff has criminal record clearance. Staff files are maintained at the facility. Staff have current CPR/first aid training and documentation of ongoing training.