Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to clear the deficiencies issued during visit made on 04/27/2026. LPA Rai met with the Office Manager Aquinas Malapitan and stated the purpose of today’s visit.

During today's visit, LPA Rai cleared one deficiencies issued on 04/27/2026 in regards to exceeding the approved fire clearance. Licensee provided a Plan of Correction on 04/28/2026 stating the plan to ensure only 25 non-ambulatory clients are at the facility at any given time and have submitted an increase for non-ambulatory status from 25 clients to 60 clients. The Department is working with the local Fire Department to inspect the facility for the updated fire clearance.

During today's visit, LPA observed three activity areas in the back with less than 20 clients in the room with 7 staff present. LPA Rai observed clients arriving to the day program and were offered to have a snack and use the restroom before staff were getting ready for community based program.

Office Manager stated the staff were trained and they have a policy and procedure in place to ensure only 25 non-ambulatory clients are at the facility at any given time.

LPA Rai provided Licensee Letter of Deficiency Citations Cleared for deficiencies issued during today's visit.

Exit interview conducted with Office Manager Aquinas Malapitan and a copy of the report was provided.