Facility Evaluation Report

LPA Audrey Jeung toured facility and grounds. This one level home consists of 3 client bedrooms and 2 staff rooms--one with a private bathroom. There is one bathroom for all residents, kitchen, dining and living rooms. Facility accommodates Level 2 Regional Center clients. No accessible bodies of water or fire safety hazards are observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are posted prominently. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 ambulatory residents present, and 1 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed; first-aid training for staff is checked. Leah Ruiz is a certified ARF administrator (x 10/2023) that oversees facility operations.

The following licensing forms/information are requested to be submitted to CCLD by 1/4/21:

- LIC 400 Affidavit Regarding Client Cash Resources

- LIC 402 Surety Bond (or proof of valid surety bonding)

- LIC 308 Designation of Administrative Responsibility

- LIC 999 Facility Floor Plan (with dimensions)

Annual fee is overdue and amount of $454 is due and payable.

Deficiency of the CA Code of Regulations, Title 22, Division 6, is cited on a following page. See also Technical Advisory note.