Facility Evaluation Report

On today’s date, Licensing Program Manager (LPM) Alisa Ortiz and Licensing Program Analyst (LPA) Rose Ruppert met with Licensee (LE), Yesenia Menjivar, for the purpose of discussing current operations at the facility after an annual visit on February 6, 2025.

Concerns regarding recent Annual visit which resulted in: one Type A, two Type Bs, two Technical Violations and two Technical Assistances

Licensee’s requirements to have the following documents on file: signed Admissions Agreements to comply with Title 22, signed Physician’s Reports for each client with the new facility name and facility number

Licensee’s requirement to complete an Infection Control Plan

Licensee’ responsibility to ensure physical plant is maintained. This includes having hot water temperatures between 105 to 120 degrees Fahrenheit, securing cleaning solutions in the garage, and having emergency lighting in hallways to non-private bathrooms

Licensee’s requirement to conduct a fire drill quarterly for each shift with documentation stating the type of emergency covered by the drill and staff members’ names who participated in the drill

The Licensee stated the following during today’s meeting:

LIcensee realized she was including clients in fire drills and not including staff. Licensee understood staff are required to participate in quarterly fire drills per Title 22 regulations.

Licensee will have an Infection Control Plan reviewed by TSP on February 27, 2025 and will submit to the Department.