Facility Evaluation Report

At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 year visit and met with Administrator, Ashley Frolich. Program Director, Adrian Fuentes, arrived during visit at approximately 10:00AM. Facility is a Short Term Social Rehabilitation home that provides care and assistance to Adults with Mental Health diagnoses. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed that there were 5 Clients in care and 5 staff members on-site.

At approximately 9:30AM, LPA reviewed Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. L PA conducted a walk-through of the facility with Administrator and observed the following: Facility is a one story home with 2 single bedrooms, 2 shared bedrooms, 3 bathrooms, office spaces, and common areas. Facility has a swimming pool on site. If clients want to use the swimming pool, there is at least one staff member supervising. Facility was clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control Plan on file. Bathrooms were equipped with necessary grab bars, and non-slip mats were present. Toxins were secure and inaccessible to clients. There was a sufficient supply of hygiene products, paper products, and linens available for client use. Mattress pads were in place or available for client use. There was a sufficient supply of perishable and nonperishable foods as required by Title 22 Regulations. Hot water temperatures for all facility sinks were found to be out of compliance with Title 22 regulations of 105 to 120 degrees Fahrenheit, measuring at 142.7F, 134.7F, 157.2F, 154.2F, and 154.9F (deficiency cited, regulation 81088(e)(1)).

LPA reviewed staff and client files and client medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files were all found to have current First Aid and CPR certification. Medication was centrally stored and secure. Facility's fire extinguishers were last inspected October 2024. Facility's last emergency/disaster drill was conducted March 2025. Facility's smoke/carbon monoxide detectors were tested and operational.