Facility Evaluation Report

On 09/07/2021 at 10:35am, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Direct Support Staff, Jesus Naranjo and explained the purpose of today’s inspection. Direct Support Staff confirmed no one has experienced any COVID symptoms in the last 10 days. LPA was allowed entry into the facility that is licensed to serve a total capacity of 5 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 75 degree Fahrenheit. LPA observed hot water temperature measured at 114.8 and 109.8 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on 11/17/2020. LPA observed mitigation plan completed. First aid kit observed to be complete. Fire drill last conducted on 08/24/2021.

- LPA observed Client #1 (C1) has been cleared to the facility. However, C1 has not been associated to the facility.

The following forms to be updated and submitted to CCLD by 09/14/2021 :

LIC 308 Designation of Administrative Responsibility

LIC 400 Affidavit Regarding Client/Resident Cash Resources

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Lead Direct Support Staff. A copy of report and appeal rights given.