Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Michelle Domingo and discussed the purpose of the visit. The facility currently has forty-five clients in care.

The facility has two buildings with twenty-six client rooms, a medication office, four bathrooms, living room, dining room, kitchen, laundry room, office, and outdoor courtyard. Facility appears clean, safe, and sanitary. LPA observed all client bedrooms had the required components and furnishings. LPA observed the bathrooms to be stocked with toilet paper, paper towels, and soap. LPA tested the water to be between 107.6 and 116 degrees Fahrenheit in the client restrooms. LPA observed the kitchen to be locked making it inaccessible to clients in care. LPA observed the knives to be in the locked kitchen. LPA observed a seven day nonperishable and two day perishable food supply on hand. LPA observed the emergency food and water supply located in the pantry. LPA observed a supply of extra clean linens stored in the pantry for client use. LPA observed the toxins and chemicals to be in a locked closet in the locked laundry room. LPA observed the medication room to be locked making the centrally stored medication inaccessible to clients in care. LPA observed fire extinguishers throughout the facility to be charged and with a service date of May 15, 2025. LPA observed the courtyard to have shaded seating for client use. LPA and AD tested the carbon monoxide detector and was found to be operational.

LPA observed the fire alarms are tested annually by Bay Alarms with the last test date being November 14, 2024, and they had passed on this date. LPA observed the last fire drill conducted on July 18, 2025. LPA reviewed staff files, and no discrepancies were observed.