Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Administrator (AD) Shelly Martinez and explained the reason for the visit. Assistant Administrator (AA) Michael Martinez arrived shortly to assist with the visit. The facility is licensed for six ambulatory clients only. Currently there are six clients at the facility.

LPA Tea reviewed six client files and four staff files. Resident files and staff files contained all the required documentation. The facility is up to date with the required quarterly emergency disaster drills, which was last conducted on August 8, 2025. AD Shelly Martinez’s administrator certificate has an expiration date of January 14, 2027. AA Michael Martinez’s administrator certificate has an expiration date of April 4, 2026.

LPA Tea along with AD Martinez toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a one-story home, the facility consists of three client bedrooms that are shared, one staff room, two bathrooms, living room, dining room, kitchen and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. The water temperature measured between 105.2 to 107.4 Fahrenheit degrees.

Common areas were clean and clear of hazards; doorways were free of obstructions. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of the visit. LPA observed sharps locked and inaccessible to clients in a drawer in the kitchen. LPA also observed toxin substances secured underneath the kitchen sink. The fire extinguisher in the kitchen is fully charged