Facility Evaluation Report

On 08/02/2022 at 12:00 PM Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Calderon was met by Administrator Josephine Santos and the purpose of today’s visit was explained. The facility is licensed to serve 45 adult clients with behavioral issues.

There are currently 12 clients in care all clients are ambulatory. The facility is a 1-story structure with 10 rooms and 5 bathrooms, activity room. kitchen and work out room, teaching rooms, computer room and staff offices.

LPA Calderon and Administrator toured the physical plant. There is no bodies of water or firearm/ammunition on the premises. All client rooms were checked and are in good condition and well maintained. LPA Calderon noted adequate lighting was provided to staff and clients, storage for client personal belongings was observed. Walls and floors were in good repair. All equipment, computers, work stations are well maintained and there is adequately PPE stocked at the time of visit. LPA Calderon observed Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA Calderon noted the following: Bathroom #1 hot water temperature properly measured at 107 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit, Bathroom #3 hot water temperature properly measured at 107 degrees Fahrenheit, and bathroom #4 hot water temperature properly measured at 109 degrees Fahrenheit, finally bathroom #5 hot water temperature properly measured at 107 degrees Fahrenheit. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were not accessible to clients. The facilities’ last fire drill was conducted by staff on 07/25/2022. LPA Calderon noted (10) Smoke detectors all were hard wired, 3 Carbon Monoxide was found in the facility.