Facility Evaluation Report

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, food, and medication review. LPA met with Anthony Ramos facility staff and explained the reason for the visit. Cory Mitchell Director of Compliance arrived 15 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 Flores and Anthony Ramos staff conducted a tour of the facility and observed the following:

Facility maintains all cleaning supplies, sharps, and medication locked in program technician office. Meals are deliver to the facility from main home per their plan of operation. Facility's kitchen stores sufficient snacks for clients. Kitchen and dining area floors and furniture were observed with dust, crumbs, and stains. All bedrooms have the required furniture, bedding, and sufficient lighting. Bedroom #2(R2) has two holes of about the size of a quarter each next to the air condition fixture and the air condition is missing temperature control knob. Smoke detector/carbon monoxide detectors were tested and are in working condition. Fire Extinguishers were last service on 3/10/22. Medication and files were reviewed for 3 clients, client #3(C3) does not have a TB test clearance on file and PRN medication was observed that does not have a physician's order. Files for 2 staff were reviewed.

Deficiencies noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Cory Mitchell Director of Compliance and a copy of this report, LIC 809D, and appeal rights were provided.