Facility Evaluation Report

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of

conducting a required annual inspection. LPA was greeted and granted entry into facility by Lead Staff Eduardo Manikad. Licensee Ludy Castro and Administrator Lynette Dizon were present for the inspection as well.

The facility is a one-story home with four client bedrooms, two bathrooms, kitchen, dining room, living room, staff room, backyard and detached 2-car garage. Facility appears clean, safe and sanitary. LPA noted five clients were away at day program. All client rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 112.9 degrees Fahrenheit and 118.4 degrees Fahrenheit in the bathrooms. LPA observed facility has emergency food and water supply. Administrator stated the fire extinguisher is scheduled for service during the week of 2/26/2024. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen and the garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet in the kitchen. The backyard has a shaded sitting/lounging area. Exit gates are unlocked. LPA noted one of the exit gates drags along the concrete when it is opened. LPA advised facility to shorten the length of the wood on the gate so that it opens and closes seamlessly. LPA reviewed three client files and four staff files. LPA also reviewed medication for three clients and P&I for all six clients. Based on record review, LPA was unable to determine if emergency disaster drills took place at the facility in 2023. A deficiency is being issued. Based on P&I review, LPA determined one client's money was short by $10. The facility replaced the $10 missing from the client's P&I at the time of the inspection. A deficiency is being issued.

Two deficiencies and one Technical Advisory were issued based on today's inspection. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility.