Facility Evaluation Report

On December 2, 2025, Licensing Program Analysts (LPAs) Kayla Adkison and Marisa Chiarelli, arrived at the facility unannounced to conduct the Required Annual Inspection. LPAs were greeted by Angela Montez, Direct Care Staff (DSP), and explained the purpose of the visit. Administrator, Margo Rudy, arrived approximately 10 minutes later and joined the inspection. Administrator certificate was posted and expires in December 27, 2025. During the inspection, one (1) staff and one (1) resident were present. All other clients were participating in off-site day programs.

LPAs, DSP, and Administrator toured the facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, kitchen, backyard, and (2) two restrooms. LPAs observed all walkways, hallways, and ramps to be free of clutter and obstructions. LPAs observed each bedroom to have the required furnishings and working lights. LPAs observed the facility to be at a comfortable temperature. Hot water temperature measured between 105 F and 120 F and was compliant with Title 22 regulations. Both bathrooms had signs posted indicating there may be water measuring over 120 F.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. LPAs observed medications and toxins to be kept locked away and inaccessible to clients in care. LPAs reviewed Medication Administration Records (MARs) and found them to be current and accurate. There were various activities available for client recreation, including games, puzzles, and craft supplies. The facility has two pet dogs in the home which are walked twice a day by clients. The facility has several bicycles accessible for client use.

Fire extinguishers, smoke detectors, and carbon monoxide detectors were observed and found to be in working condition. The facility is conducting fire drills monthly with the last drill being documented in November 2025. Additional disaster drills are being conducted every six (6) months with the last being conducted in July 2025. LPAs observed a complete first aid kit ready for use.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPAs reviewed a total of five (5) client files and three (3) staff files which contained all the required documentation. All staff are fingerprint cleared and associated to the facility.

No deficiencies are being cited as a result of this inspection. Exit interview conducted. A copy of this report and was provided, via email, to Administrator Margo Rudy, via email.