Facility Evaluation Report

On 11/07/25 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA was met by staff one, Kym Nator - Assistant Administrator (S1) and also by staff two Diane De Asis-Wheelhouse - Assistant Administrator (S2) and the purpose of the visit was explained. The facility is licensed to operate for clients ages 18-59 as all ambulatory status only.

The facility is a two-story structure located in a commercial neighborhood. It consists of the following: Thirty-six (36) client's rooms and thirty-two (32) bathrooms, an activity room, a dining area, a commercial kitchen, and a courtyard patio area.

LPA toured the physical plant with staff one, Kym Nator (S1). There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. The client rooms inspected are listed as follows: #5, #8, #14, #15, #18, #19, #22, #24, #33, and #39. All call buttons were initially not in working condition. Call receiver in the medication room was repaired and tested at 11:40AM and all tests were observed to be in working condition. Bathrooms were operational and showers were in clean condition, without mold or mildew. Water temperatures were measured between 115.6 – 124.7 degrees Fahrenheit (°F), outside of title 22 regulation. Water temperature dials for floors one (1) and two (2) were observed to be at 125°F and were lowered to 115°F. Water temperature was checked once again in rooms #22 and #14 and water was within title 22 regulation. A comfortable temperature was maintained in the facility at around 68°F.

LPA observed the facility to be sanitary and furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Report continues, please see LIC809-C .