Facility Evaluation Report

At approximately 9:30AM, Licensing Program Analysts (LPAs) Felias and Contreras arrived unannounced to conduct a Required 1 Year visit and met with Administrator, Nestor Balauro. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 4 Non-Ambulatory Clients and have an approved hospice waiver for 1 individual. Upon arrival, LPAs was informed that there were four clients in care with all clients out of the facility attending Day Program and five staff members on-site.

At approximately 9:50AM, LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs reviewed staff files, client files, client medication, and P&I monies. Staff files had current First Aid and CPR certification. Client files were found to be well organized, thorough and contained the required documentation. Client medications were centrally stored and secure. P&I monies were documented, secure and not commingled.

LPAs requested the following documents to update facility file:

Designation of Facility Responsibility (LIC 308)

Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) within 30 days of visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.