Facility Evaluation Report

06/17/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 5 clients in care. 1 client was present during inspection, all other clients were at day program. LPA was greeted by staff member. Administrator, Cluvens Deliska arrived later during inspection.

LPA and staff member toured the building and grounds. The facility was found to be at a comfortable temperature. LPA spoke with administrator about ensuring facility has 2 day supply of perishable and 7 day supply of non-perishable food.

All rooms were furnished per regulation. Extra linens were available. Water temperature in sinks accessible to clients in care were measured and found to be within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 02/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Chemicals and sharps were located in a kitchen drawer and under the kitchen sink and found to be secured. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. P&I monies were documented. Facilities last fire/disaster drill was conducted 06/04/2025.

LPA conducted a review of 3 client records. All records had the required documentation. LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required training as well as current 1st Aid & CPR certification on file.