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. At around 8:02 AM, LPA Tea was greeted and granted entry into the facility by DSP staff, Alicia Torres, Rosa Villegas, and Roberta Grande and explained the reason for the visit. Facility is licensed for 32 clients, six clients may be non-ambulatory. Currently there are twenty nine clients during today's visit. The Administrator, Mariles Borja and administrator in training Dennis Mendoza arrived shortly after to assist during the visit.

At 8:45 AM, LPA Tea reviewed six client files and four staff files. client files and staff files contained all required documentation. Administrator certificate expires on April 03, 2025.

LPA Tea along with the administrator in training Dennis Mendoza and DSP staff Michelle Santos toured the facility at 9:49 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility consist of 4 residential buildings. The South House, houses six clients. The Main House houses 12 clients. The Back House houses one client. The Front House houses ten clients. There is another additional unit on the facility premises that stores the facility food items and the other part is the recreational room for staff and clients. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident 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 shower was free of mold/mildew. Water temperature measured between 105.2 F degrees and 122.0 F degrees. The maintenance technician fixed the water temperature to meet regulation standards while on site in one of the restrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit.