Facility Evaluation Report

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual required visit. LPA met with facility staff C. Malbas and explained the purpose of the visit. Staff contacted management staff via cell. Program Director (PD) Angel Carter and Director of Residential Services (DRS) Carolyn Rapier requested LPA Valerio conduct the rest of the visit PD and DRS.

The facility is a two story residential home licensed to provide services to adults 18 years of age and older, all of which need to be ambulatory. LPA observed 1 staff on shift and 7 residents in the home. 1 resident was out on an outing during the visit. LPA Valerio and Facility Staff Malbas toured the facility to ensure compliance with Title 22 regulations. LPA observed both floors of the facility. Resident bedrooms were furnished, clean, and free from debris. Resident bathrooms were fully stocked with paper towels, a trash can, and hand soap. Common areas were fully furnished. Technical Assistance was provided for a couch located on the second floor of the common living area. The couch had one area on the seat that was pealing and torn, which needs to be replaced. The facility was observed to have an emergency supply of food, emergency supplies, and multiple first aid kits. Sharps, toxins, and cleaning supplies were locked away and inaccessible to residents in care. LPA observed fire extinguishers, a fire pull alarm system, and carbon monoxide detectors to be in working condition. The facility's last emergency drill was conduct on October 18, 2023. LPA observed staff assisting residents with medications, questions, and administrative task. Residents were observed cleaning their room, practicing yoga, listening to music, and completing their ADLs.

LPA was met by PD and DRS to carry out the rest of the annual inspection. LPA was provided facility files. LPA reviewed 3 staff files and 4 resident files. Staff files were observed to be complete with up to date training and background clearance. Resident files were observed to be up to date with necessary files. Administrator Anthony Garcia no longer works for the organization. DRS Rapier stated that the facility communicated with the Regional Office regarding the administrator change.