Facility Evaluation Report

on 12/5/2025, at 1:46pm Licensing Program Analyst Noel Wolf Petersen arrived unannounced the facility to conduct an annual inspection. There is a maximum capacity of 6 people and 3 currently, housing adults 18 to 59. 1 client has diabes, controlled via diet.

Physical inspection included but was not limited to the bedrooms, bathrooms, kitchen, common areas, storage areas, exteriors, and evacuation routes. facility is clean, the traffic areas are well lit and unobstructed. Bedrooms have required furniture, LPA gave guidance about the mattress encasements. Bathrooms have hardware in good repair. Kitchen has adequate food for 2 days perishable and 7 days non perishable, light needs new bulb, administrator got a work order. LPA gave guidance to add a date when your using leftovers, monitor carefully for signs of expiration and ere on the side of overly cautious to avoid serving expired food. 2 clients at random were reviewed for medication and MARs, the drugs were in agreement with the log. 1 client uses the P+I at the facility, the other two have different arragements. P+I is in accordance with the record. exterior and common areas are free of trip hazards, evacuation route gate swings freely and latches closed. Fire extinguisher is dated 8/14/24, the water is measured at 120*F, Smoke/co alarm is functional. Fire department may have arragement for 2027, LPA, asked for the 9054 fire clearance to be sent to noel.wolfpetersen@dss.ca.gov

3 of 3 clients files were reviewed, for the admission agreements, 602 medical assessments, Ipp's and Needs and services plans. Documents are up to date and present.3 of 3 staff files were reviewed, for fingerprinting, background checks, cpr/first aid training, and ongoing training related to the different and specific needs of the clients. LPA gave guidance the Diabetic types of training would be a good idea. Administrative records were reviewed, Evacuation control Plan, Infection control plan, Facility Posters(Personal Rights, ombudsman, federal workers rights, facility sketch with evacuation route), Grant Deed, and Surety bond are up to date and present.

No citations were issued, a copy of the report of was read and given to the administrator, an exit interview was conducted.