Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 07/15/2025. LPA Ramirez was met by Administrator Joel Alonzo and explained the purpose of the visit. The facility is licensed serve thirty-four (34) mentally disabled clients 18-59 years old, of which all must be ambulatory. There are 4 Units which are the client living quarters. Each unit has 2 stories. On the first floor of each unit, there is a living and dining area, kitchen, a bathroom which is shared by the clients and 2 bedrooms. The clients do not cook in the kitchens. Each bedroom has 2 beds. Upstairs, in each unit, there are 2 bedrooms, a bathroom which is shared by the clients, and a storage closet.

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

Infection Control- Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Facility has an Infection Control Plan in place.

Physical Plant & Environmental Safety- Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to clients. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) shared client rooms. All the clients’ bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees. LPA Ramirez observed walls in client room#303 located in building 3 to be unsanitary with yellow/brownish stains and grime. LPA Ramirez observed all doors to buildings 1,3,4 to be wide open and observed more than 4 flies in buildings 1,3,4. LPA Ramirez will issue two (2) deficiencies based on these observations.