Facility Evaluation Report

LPA Jeung toured facility and grounds. This 4- bedroom home has 2 full bathrooms, kitchen, office, and living area. There is a rear deck and level, fenced back and side yards. A detached storage shed is in the backyard. There are no accessible bodies of water nor fire safety hazards observed. In each clients' private bedroom, there is a locked medication cart. Toxins are stored appropriately and inaccessible to clients, and facility is clean, safe, sanitary and in good repair. Hot water temperature is tested in main bathroom at 106 degrees. Carbon monoxide detector is tested and operable. Food supply--consisting of liquid nutrition for 2 residents--and first-aid kit are inspected and complete. Some client files are reviewed, including centrally stored medication records. Disaster drills are documented; the most recent was performed 6/1/24.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Luz Canares is a certified ARF administrator (x 2/25) that oversees facility operations. There is no staff room, as facility employs awake night staff.

The following licensing forms are to be completed and submitted to CCLD by 6/21/24:

• LIC 308 Designation of Administrative Responsibility

• LIC 400 Affidavit Regarding Client Cash Resources

The following documents are provided to LPA:

Deficiency of the California Code of Regulations, Title 22, is cited on a following page. Also, see Technical Violations, 4 pages.