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 staff. Administrator (AD) Leilani Alejandro and Administrator (AD) Antoinette Nichols arrived shortly to assist with the visit. Facility is licensed for six clients and two may be non-ambulatory. Currently there are three clients residing at the facility.

LPA Tea reviewed three client files and one staff file. Client and staff files had the required documentation. There were a few discrepancies upon reviewing client and staff records. AD Alejandro’s administrator certificate expired on December 2, 2025, she has completed all required course work and is pending renewal. AD Nichols’s certificate expires on January 16, 2027. The last disaster drill was conducted on November 17, 2025.

LPA Tea along with staff and administrators toured the facility. 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 first 125.7 Fahrenheit degrees. AD Nichols adjusted the water boiler and then the water temperature got too low. LPA explained to administrators and staff that water temperature needs to be between 105 Fahrenheit degrees to 120 Fahrenheit degrees. There is a warning sign in the