Facility Evaluation Report

On December 22, 2025, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator Leilani Alejandro was available to assist with the facility inspection.

The facility is licensed for six (6) ambulatory Developmentally Disabled Clients ages 18-59 years old. Facility has census of three (3) clients. Currently, there is one (1) client present during today’s visit. Two clients are in Day Program.

Facility is a single story with attached garage facility. The facility has four client bedrooms and two bathrooms.

LPA conducted a tour of the physical plant accompanied by Administrator Leilani Alejandro, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were operational with water temperature measured between 114.9 to 115.7 degrees F. A comfortable temperature of 64 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for sharps objects and toxins were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has supply of emergency food and water. A fire extinguisher was fully charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance. CONTINUED ON 809C