Facility Evaluation Report

Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced required annual (mitigation) inspection. LPA was greeted and granted entry and completed the Coronavirus 2019 screening procedure. LPA met with Program Manager (PM) Laura Forshythe Martinez and Registered Nurse, Sunny Leos who joined shortly around 9:40 am. LPA stated the purpose of the visit and LPA and PM conducted a tour of the inside of the facility.

During the inspection, LPA observed 22 clients on site as the remaining clients were on a hybrid schedule learning from home. LPA observed 52 staff present wearing PPE. LPA inspected common areas, storage areas, activity rooms, offices, and bathrooms. All areas were clean and organized and found no health and safety issues. Hot water was measured 117.6 degrees Fahrenheit in the Changing Room and 118.5 degrees Fahrenheit in the Kitchen, 117.3 degrees Fahrenheit in the client's bathroom on the second floor. LPA observed a janitor cart with cleaning solutions in the kitchen but was removed and locked away in the Janitor's Room. LPA observed the facility and had sufficient PPE supplies over 30 days’ worth, cleaning, and incontinence supplies all of which were properly locked and stored. LPA, PM, and Job Coach Rene Rosales could not test and operate the new smoke detectors as they were recently installed during the renovation. PM provided a receipt of the fire alarm system dated 04/11/2022 to ensure that it was tested and passed. PM will test the system tomorrow and submit a recording to LPA Cho. Medications, cleaning supplies, and sharp items were inaccessible to the clients in care. The fire extinguishers were mounted and charged. LPA provided a technical assistance regarding adding a gate at the bottom stair in the Mezanine Room and to submit a recording of the testing of the smoke detectors. LPA reviewed the approved COVID-19 mitigation plan. For this visit, there are no deficiencies cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit and LPA Cho will follow-up with the corrections. An exit interview was conducted with Program Manager Laura Forsythe Martinez and a copy of this report was provided.