Facility Evaluation Report

On 3/25/26, Licensing Program Analyst (LPA) Kyle Wellington made an unannounced visit to the facility to conduct an annual inspection. LPA met with Assistant Director (AD), Melissa Duenas, who was informed of the purpose of the visit. The facility has a fire clearance for a total capacity of 60 non ambulatory adults. AD reported 48 clients, 16 staff and 2 nurses were present for the day. At the time of the inspection, there were zero (0) clients and staff at the facility. AD informed LPA that the facility is a licensed vendor of the Inland Regional Center. LPA received a resident and staff roster from the AD. LPA did an observation of the inside of the facility with the AD and conducted record reviews for the inspection.

The facility is made up of a large multi purpose room, five (5) restrooms, three (3) changing rooms, kitchen, media/serenity/arts rooms, conference/break rooms and a nurses office. LPA observed cleaning supplies were kept in a locked closet. LPA observed the kitchen to be clean and organized. AD informed LPA that clients provide their own lunches and snacks to consume during day program hours. LPA observed the restrooms to be clean and sanitary with soap, toilet paper, paper towels and incontinent supplies to be readily available. Hand sanitizer was also available throughout the facility. AD informed LPA that 15 clients receive medication at the facility. LPA observed the medication to be secured in a locked cabinet in the nurses office. LPA reviewed the Medication Administration Record (MAR) for the clients. LPA reviewed the facility’s fire alarm system inspection report conducted by SSD Alarm noting the fire alarm system is functioning properly and it was inspected on 3/13/26. LPA reviewed the facility’s Fire Drill records noting the last fire drill was conducted on 1/20/26. LPA observed several fire extinguishers charged and mounted throughout the facility that were last serviced on 1/13/26. LPA observed that all facility exits were clear of obstructions and had the required signage. LPA reviewed several staff and clients files.