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 Direct Support Professional (DSP) Donabel Esguerra. Administrator (AD) Leilani Alejandro arrived shortly to assist with the visit. Facility is licensed for six clients and two may be non-ambulatory. Currently there are four clients residing.

Around 8:15 AM, LPA Tea reviewed three client files and two staff files. Client and staff files had most of the required documentation. There were a few discrepancies upon reviewing client and staff records. Client records had only Orange County Regional Center admission agreements. LPA advised to include a separate admission agreement for licensing that meets Title 22 standards. Looking at the staff records there were no, health screenings. AD Alejandro’s administrator certificate has an expiration date of March 1, 2026. She has not received a physical copy yet due to backlog.

LPA Tea along with AD Alejandro and DSP Esguerra toured the facility at 9:17 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 3 client bedrooms, 3 staff rooms, 3 bathrooms, living room, dining room, and kitchen. 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 resident 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 very high at 141.8 F degrees. LPA explained to AD and staff that water temperature needs to be between 105 F degrees to 120 F degrees, anything higher needs warning signs posted around the bathroom faucets. Staff adjusted the water temperature and posted warning signs. 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 bandages, tweezers, thermometer, and scissors.