Facility Evaluation Report

At approximately 9:20AM, Licensing Program Analysts (LPAs) Felias and Magdaleno, arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Sandra Martinez. Administrator, Thelma Adona , arrived during visit at approximately 9:45AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance for 6 ambulatory, of which 2 can be non-ambulatory, and a total capacity for 6 Clients. Upon arrival, LPAs was informed that there were 4 clients in care, and 1 staff member on-site.

LPAs reviewed Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs conducted a walk-though of the facility with Administrator. LPAs observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 3 Client bedrooms, 1 staff room, 2 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

LPAs reviewed staff and client files, client medication, and P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. P&I monies were documented, secure and not commingled. Medication was observed to be centrally stored and secure. Administrator's Certificate for Thelma Adona (7002581735) was current with an expiration date of 10/13/2025. Fire extinguishers were last inspected June 2024. Smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted December 2024.