Facility Evaluation Report

04/03/2025, 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 3 clients in care. Facility approved/cleared for 6 ambulatory only.

At approximately 9:30 AM, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature and passageways were free from obstructions. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Facility stores emergency supplies in the hallway closet.

All rooms were furnished per regulation. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 112.4 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 07/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facilities last fire drill was conducted 03/02/2025. Toxins, sharps and other items that could pose threat if available to clients were located 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 on the Centrally Stored Medication Record. However, LPA observed expiration dates for medications to not be filled out on the Centrally Stored Medication Log. Client cash resources were documented.