Facility Evaluation Report

On 10/02/2023 at 09:00 AM Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit using the CARES tool. LPA was met by Administrator, Josephine Santos (S1), and the purpose of today’s visit was explained. The facility is licensed to serve 45 adult clients with behavioral issues.

There are currently fourty-four (44) 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 and Administrator toured the physical plant. There are no bodies of water or firearms/ammunition on the premises. All client rooms were checked and are in good condition and well maintained. LPA 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 was adequate PPE stocked at the time of visit. LPA observed Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA noted the following: Bathrooms #1-5 hot water temperature properly measured between 105 and 120 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 eighteen (18) clients and eight (8) staff on 09/07/23 at 10:32AM. LPA observed 18 Smoke detectors, all detectors were individual with proper battery supply. Four (4) working Carbon Monoxide detectors were found in the facility. The facility's four (4) Fire Extinguishers were checked and found to be fully charged as of 08/07/23 and all were accessible .

Three (3) clients files were reviewed and found to be complete. LPA reviewed two (2) client’s medications and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. The facility does not handle client’s money/cash resources. All the required documents are posted in the facility in a visible area to staff and clients.