Facility Evaluation Report

Licensing Program Analysts (LPAs) Pamela Bunker conducted an unannounced required 1-year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPAs were properly screened for COVID-19 symptoms and their temperature was checked. LPA Bunker met with the Lead Clinical Supervisor Shelly Mayers. LPA Bunker explained the purpose of today's Annual Inspection. LPA Bunker verified that the facility has an approved mitigation plan report. The facility's annual fees are current. The facility currently has (9) ambulatory clients in placement.

The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The facility is a two-story building located in a business/residential neighborhood. Lead Clinical Supervisor Ms. Mayers and LPA Bunker made a complete tour of the facility which consisted of upstairs and downstairs.

The downstairs consists of the main office, living room/common area, dining room/group meeting area, kitchen, Administrator's office, Counselor's office, Therapist's office, medication room, arts, and craft closet, two (2) all-gender bathrooms, utility closet emergency supplies room, and numerous of storage closets are downstairs. The upstairs has seven (7) bedrooms, two (2) all-gender bathrooms, one (1) all-gender staff restroom, laundry room, staff lounge, Doctor's office, Director's office, and numerous storage closets. The outside includes a gated front parking lot, a backyard-covered patio/shaded areas, and indoor/outdoor activity areas.