Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/22/23 at 12pm to conduct a Required -1 Year visit. LPA was unable to reach facility staff due to facility out in community. LPA returned today at 9:30am on 9/25/23 to conclude the annual visit. LPA met with Administrator(s) Nelson Gomintong and Ruth Gripo and stated the purpose of today’s visit. Administrator certificate for Nelson Gomintong expires 11/14/2024.

LPA was allowed entry into the facility that is licensed to serve 16 ambulatory clients of which 6 maybe non-ambulatory . Annual Fees are current. Facility staff roster provided during this visit. Upon arrival LPA observed clients participating in activities in the community. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed the facility does not prepare food nor store medications for the clients. LPA observed the facility conducted fire drills on 7/14/23. LPA observed a pull alarm fire system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. The temperature inside the facility was measured at 68*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was not measured during this visit as the water pressure was not adequate and washers were needed for the sinks. The water heater was replaced in 2019 but the facility will contact the building management and/or a plumber to ensure the sinks work properly and the temperature is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. An Advisory Note was given in lieu of a citation during this visit as clients are currently in the community and will not return today. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. Upon a file review the following items were discussed to be submitted with any changes annually: Any addendums to Infection Control Plan (LIC9282), Designation of Facility Responsibility (LIC308), Liability Insurance, Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610E),

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, copy of report given.