Facility Evaluation Report

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit with focus on the infection control domain, food and medication review. LPA met with George Ricciardella Director Development and explained the reason for the visit. Phil Wilkens Chief Information Officer arrived 30 minutes later .

The facility is a two floor structural home located at the back of a community of single homes. The facility is licensed to served 6 ambulatory adults between the ages of 18 - 59 years old. The facility serves as a Transitional Rehabilitation Program. There is an outdoor shaded area in the front, there are no large bodies of water, facility has 3 client rooms, 2 client bathrooms, a living room down stairs and upstairs, kitchen and dinning room are located in the 2nd floor, a therapist office upstairs and downstairs, a program technician office downstairs, and a case management office in the 2nd floor.

LPA observed all common spaces in good repair and clean. Bedroom #1(R1) has a built in drawer in bed missing, bedroom #2(R2) does not have sufficient lighting and built in drawer under bed broken, built in drawers in beds are used as chest drawers for clients storage. Bathroom #1(B1) has rust build up in shower hose ring, no sufficient lighting, and water temperature was tested at 123.1 degrees F; bathroom #2's(B2) shower tub paint has a peel patch of about 6 inches long and 3 inches wide and water temperature was tested at 77.5 degrees F which are not under the recommended temperature of 105 - 120 degrees F . Facility's kitchen maintains snacks and dishes only, client's 3 meals per day get prepared at main house and delivered at the facility per meals schedule, LPA observed a digital meal tracker that is maintain. Facility maintains medication, knives, and cleaning/disinfecting supplies in the program technician office which is locked at all times and accessible to staff only. Fire extinguishers are located outside the building in glass cases and up to date. Smoke/Carbon monoxide detectors were observed and tested throughout the facility . LPA reviewed medication for client #1(C1) and client #2(C2).

COVID 19 recommendations are being followed regarding screening, isolation procedures, and training.