Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Konishi 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.

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

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an Infection Control Plan in place. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.

Physical Plant & Environment Safety: A tour of the facility includes: First Floor: front desk office, lobby, dining area, kitchen, laundry room, staff office, group room, mud room (with restroom and shower), one (1) restroom, one (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, six (6) bedrooms, three (3) restrooms, three (3) shower rooms, tech station, laundry room, staff lounge, and staff restroom. 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. Extra linens and blankets are stored in the Laundry room. The hot water temperature was measured throughout the facilities client shower rooms and measured between 105.4 degrees F to 117.8 degrees F which is within the required range of 105-120 degrees.