Facility Evaluation Report

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Joannalyn Agbayani,co- administrator . There are currently 4 residents at the facility. There were 2 staff on site at the time of inspection. All four residents were attending Day Programs.

LPA toured the facility, all exits were unobstructed, and the facility was found to be clean & at a comfortable temperature of 74 F. Water temperature measured 112 F. Bathrooms had soap and paper towels, non-skid mats for showers and baths. Designated staff have current first aid certifications in file. Fire extinguisher was charged and serviced 07/17/2023. Carbon monoxide detector and smoke detectors were operational. Last fire drill was on 12/5/2023 for all shifts. The facility has an ample supply of perishable and non-perishable foods as required by Title 22.

LPA requested the following updated forms to be submitted to Community Care Licensing by 01/01/2024:

· LIC 308 Designation of Facility Responsibility (1 person per form)

· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)· Copy of surety bond

· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.