Facility Evaluation Report

Licensing Program Analyst (LPA), Alviso arrived to conduct a required-1 year inspection, on 7/15/25 at approximately 12:25pm, and met with Lead Judy Columbo, Licensed Psychiatric Technician (LPT). LPT Judy is the back-up Administrator when needed, and today she is covering Administrator position.

Facility is fire cleared for four(4) non-ambulatory, of which four(4) may be bedridden. There are four(4) clients in care. One(1) of the four(4) clients attends day program. Facility has a required infection control plan. Facility has a required emergency disaster plan.

LPA reviewed four (4) client files. Client files are complete. LPA reviewed five (5) staff files. Staff had required first aid, CPR, personal rights training, and emergency disaster training as required. Staff have training, including refresher training's completed monthly per review of facility records.

LPA reviewed four (4) resident files. All files were complete per review of records.

LPA reviewed seven (7) staff files. All staff had required criminal record clearance. All staff had first aid and cpr training. Staff had required restraint training, initial hours/annual hours, when facility uses client emergency intervention plans, including restraint.

The LPA toured the facility with LPT Judy Columbo. Hot water was measured at 113.3 degrees Fahrenheit, which is within regulation requirement.