Facility Evaluation Report

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 10:20AM. LPA met with Residential Supervisor (RS) Inguilber “Ingui” Alcantar and reason for the visit was explained. Entrance interview conducted. HR Manager Karina Diaz and Residential Manager Leopoldo Vaca arrived at 11:02AM and Compliance Specialist Regan Mew arrived at 11:15AM during the inspection.

Beginning at 10:21AM, the LPA, along with RS Alcantar toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS (TREATMENT/THERAPY/OFFICE AREAS): At the time of the visit, treatment, therapy, and office furniture were observed to be in good condition. The LPA observed clients in common areas using computers at the time of the inspection. Group and individual activities are available. The facility maintained a comfortable temperature. LPA observed several fire extinguishers throughout the facility that were fully charged and last serviced 04/29/2024. LPA observed required postings throughout the common space. There is a separate laundry room, which is kept inaccessible to clients and contains locked detergents.

MEDICATIONS: Medications review began at 10:26AM; medications are centrally stored and locked in the medication room on the first floor. Medications are labeled and checked for expiration dates. Medications are documented and updated on a digital record used by facility staff. LPA observed the centrally stored medications and destruction record to be missing dates started. LPA observed the digital records and observed proper logging and documentation of the medications. LPA discussed with facility staff and explained that the centrally stored medications and destruction record shall be kept up to date alongside digital records.