Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Program Director Karen Gordley who assisted with the visit. The purpose for today’s visit was explained.

The 2 story facility is a short-term Crisis Residential Program licensed to serve 16 Ambulatory and 2 Non-Ambulatory clients ages 18-59.

A tour of the facility includes: First Floor: front desk office, lobby, dining area, kitchen, laundry room, 2 client bedrooms, staff office, group room, mud room (with restroom and shower), 1 restroom, 1 shower room, storage rooms, medication room, electrical room, elevator, and outdoor patio area. Second Floor: elevator, storage room, laundry, living room area, electrical room, 6 bedrooms, 3 restrooms, 3 shower rooms, tech station, laundry room, staff lounge, and staff restroom.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility has a valid Infection Control Plan and have sufficient PPE supplies.

Physical Plant & Environment Safety: Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. Hygiene products are readily available and stored in a storage room. The hot water temperature was measured throughout the facilities client shower rooms and measured within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are centrally stored and kept locked and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance, facility has an emergency sprinkler system throughout the facility. The fire extinguishers were observed and fully charged.

Staffing : The facility has sufficient staffing and training's are documented electronically on Relias.

Personnel Records-Training : Staff files are maintained electronically, LPA reviewed 4 staff files during todays visit. 1 staff file was missing training's from file, 2 staff were missing first-aid training/certificates, 1 staff was missing their health-screening/TB test. All staff are finger print cleared. (Continued on LIC809-C)