Facility Evaluation Report

Licensing Program Analyst (LPA) Audrey Jeung conducted an unannounced annual visit and toured the facility, consisting of four private client rooms, one full bath/shower room, a half bathroom, dining area, small office, kitchen and living room. Bathrooms are observed clean and odor-free, equipped with liquid soap and paper towels. Indoor and outdoor passageway are free of obstructions and no accessible bodies of water or fire safety hazards are observed. A comfortable temperature is maintained and lighting is sufficient for comfort and safety. This is a single story facility with one car garage, where washer and dryer are located. Water temperature is tested in main bathroom. Medications, sharps, and chemicals are observed locked and inaccessible to residents. Food supplies of perishables for 2 days and non-perishables for 7 days are maintained. First aid kit is observed to be complete. Carbon monoxide detector is tested and operable. No residents are present during the visit as they are attending their day programs.

Client records and 5 staff records are reviewed. Centrally Stored Medication Records are maintained and reviewed. Emergency drills are documented as conducted quarterly.

The following information/forms are requested to be submitted to CCLD BY 7/7/26:

- Affidavit Regarding Client Cash Resources (LIC400)

- proof of control of property (current signed lease agreement)

The following information is provided today: Personnel Report (LIC500), Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Emergency Disaster Plan (LIC610D).

No deficiencies of the California Code of Regulations, Title 22, are observed. See Technical Advisory Notes --3 pages. Report is reviewed with manager and a copy is provided.