Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with Program Director (PD), Nai Saechao. PD stated the current resident census is 26, with 10 staff on duty.

The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on December 12, 2024.

LPA toured the facility with PD to include the activity rooms, office, kitchen, bathroom, staff break room, storage, office, exterior, and transportation vans. LPA tested facility exits. All exits tested have an auditory alarm, which sounds to the front desk. LPA tested facility water temperature, which was measured to be at 116 degrees F.

During touring LPA noted a staff to client ratio of 1:3. PD stated the staff to resident ratio is 1:3. PD stated he currently doesn't have any resident who is a 1:1.

LPA observed 1 out of 3 transportation vans with the PD. PD stated the facility currently doesn't have any residents who are non-ambulatory.

LPA reviewed staff training records for the first and second quarter of 2025, which included: Coaching & Mentoring Skills/Vehicle Accident procedures, Clients Rights, Vehicle Safety, Aggressive Behavior, Data collection/ Service Notes. Page 1 Out of 2.