Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. Administrator Lydia Sattiewhite arrived shortly after.

RECORDS: A review of facility files was initiated at 10:00 a.m. Facility records are stored in the locked cabinet in a supply room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 12/16/2025). The LPA obtained Client Roster, Staff Roster and Insurance liability. The LPA reviewed five(5) client files. All records were complete with pre-admission appraisals, needs and services plans, physician reports, admission agreements, and emergency contact information. The LPA reviewed five (5) staff files, All records were complete and current.

The LPA toured the physical plant with staff to ensure there are no health and safety hazards. LPA observed fire extinguishers throughout the Day Program which were last serviced 11/10/2025 and appeared fully charged. The carbon monoxide and smoke detectors were tested and functioned properly during the visit.

RESTROOMS: The restrooms were observed to be clean, sanitary, and in operating condition. The LPA

observed sufficient amounts of soap and paper products, as well as hand washing signs. LPA tested the hot water temperature to be at 107.5* in the women's restroom.

Report will continue on LIC809-C, 2nd page.