Facility Evaluation Report

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 70 ambulatory clients and 5 non-ambulatory clients. LPA met with Administrator (AD) Yuridia Luna.

At 9:10am, AD conducted facility tour. LPA observed that the facility has designated rooms for different activities which include but are not limited to activity rooms, a computer room, an exercise room, a media room, dining room, private changing areas and two restrooms for client use, male and female. At 9:20am, LPA tested the water temperature in the client men's restroom where hand washing is done and the measurement was 83.6 degrees F. During the tour, LPA did not observe any item accessible to clients which would pose a risk to their health and safety. LPA observed 4 clients exercising in the exercise room. Vehicle registration is current. The facility maintains a locked location for chemicals. Evacuation plan, clients rights, facility license, and emergency disaster plan and emergency exits are posted on the wall.

LPA reviewed 4 client files and 5 staff files. Three out of four client files contained required documentation including admission agreements, physician reports, needs and service plans, and consent forms. Staff files reviewed, included medical assessment/ TB, criminal record clearance and proof of CPR training. Two out of five staff files reviewed contained partial or outdated required training.

At 10:40am, LPA reviewed the disaster drill log with the last drill was conducted on 7/3/2024. Fire extinguishers were charged. LPA was unable to verify the last time the fire safety systems were last maintained. LPA reviewed the Emergency Disaster and Infection Control Plans.