Facility Evaluation Report

On 8/22/2025 at 08:40 AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA was greeted by Executive Director (ED) Tammy Chavez and gained access to the facility. LPA explained the purpose of the visit to the ED.

The facility has eighty six (86) bedrooms, ninety bathrooms (92) bathrooms, kitchen, dining room, activity room, and courtyard. The facility is licensed for 150 ambulatory of which 30 can be non- ambulatory 1 maybe bedridden. LPA completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 118 degrees Fahrenheit. The facility is equipped with operational smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book. LPA observed that facility sketch is not posted for both floor. Technical violation issued.

Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure Med-room inaccessible to clients. The facility had emergency water. LPA observed that the facility does not have enough food for 72 hour emergency. Citation issued. There are no firearms and ammunition in the facility.