Facility Evaluation Report

At approximately 12:00 PM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a Case Management - Annual Continuation inspection and met with Cecilia Morales, Licensee/Administrator. Facility is an Adult Residential Facility with three (3) ambulatory clients in care, all of whom were away at Day Program.

At approximately 12:10 PM, LPAs initiated a brief facility tour with Licensee to follow up on issues noted during the initial annual inspection visit on 11/22/2024. Water temperature in the third bathroom tested at 105.9 degrees F during today's inspection which is within the allowable range of 105 to 120 degrees F per Title 22 regulation. All sharps and items which could pose a risk to clients were observed locked and inaccessible to clients in care. LPAs inspected facility's food supply which was observed to be free from expired items and was in compliance with regulation. All the required posters were observed hanging in a conspicuous common area of the facility. The facility telephone was tested and operational during inspection. The shed in the backyard was observed unlocked. LPAs advised Licensee to ensure the shed remains locked at all times to remain in compliance with regulation. Licensee locked the shed immediately and agreed to ensure it remains locked.

Licensee states the facility conducts bi-annual disaster drills, with the most recent drill conducted 9/2024. LPAs reminded Licensee that disaster drills are now required to be conducted on a quarterly basis.

LPAs followed up on the facility's fire clearance for the staff living quarters in the garage, and Licensee provided LPAs with the updated signed and approved fire clearance from the fire marshal stating that the bedroom in the garage is approved for staff use only.

At approximately 12:40 PM, LPAs began file review. Five (5) staff and three (3) client files were reviewed.