Facility Evaluation Report

Licensing Program Analyst (LPA) E.Conchas arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with Manager, Pat Duncan. LPA explained the purpose of the visit.

FACILITY: The facility is licensed for 60 ambulatory and 20 non-ambulatory for a total of 80 clients. LPA toured the facility inside and out with the managers.

INDOOR: LPA observed activity rooms for arts & crafts, card games, cooking, sewing, grooming, work opportunities, and education.The facility has no firearms. The facility has charged fire extinguishers and carbon monoxide detectors. The facility uses a fire alarm control panel based system with last inspection completed by SSD alarms on 2/3/2025. The facility has safe and healthy indoor activity space for clients. The facility provides snacks for the clients. The snacks were stored in a safe and healthful manner. The last Earth quake drill was conducted on 11/7/2025 and Fire drills was conducted on 11/03/2025. Cleaning supplies, knives, and toxins were locked and kept inaccessible to clients. Client restrooms were maintained in a safe and sanitary condition. LPA measured the hot water temperature in the client restrooms. The water temperatures measured 98 degress F. Manager adjusted the water temperature and will send update to LPA.

DISPLAY: LPA observed Facility sketch, snack calendar, activities calendar, Personal rights, Droplet/ Infection precautions, See something say something and emergency plan.

OUTDOOR: The outside of the facility had shaded area for seating. LPA observed a basketball court and a gardening section. No obstruction was observed in passageways.