Facility Evaluation Report

On January 23, 2025, at 09:00 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Director of Admissions, Michelle Ly, and disclosed the purpose of the inspection. The Director of Operations (DO), Sajana Sagar, and Director of Quality Improvement (DI), Julia Phillips joined shortly after. The DO informed the LPA that the facility had (8) clients in care and (5) staff members present at the time. (7) clients were away at their day program and (1) client was at the facility.

At 9:48 AM, the LPA initiated a walk-through of the facility, accompanied by the DO.

LPA inspected the kitchen and found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The sink was empty, and no dirty dishes were observed. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA inspected the fire extinguisher mounted on the wall in the kitchen and found it fully charged, with the last service tag dated 11/26/2024.

LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. A non-slip rug was placed under the dining table and chairs. The LPA observed playing cards, board games, puzzles, and other recreational activity items for the clients in the dining area.

LPA inspected a locked closet in the hallway, containing detergents, soap, and cleaning supplies. The DO tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional.