Facility Evaluation Report

Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Cory Mitchell and discussed the purpose of today’s visit.

This facility serves as a Transitional Rehabilitation Program and is licensed to serve (6) ambulatory clients. This facility consists of a 2-story building. The downstairs consists of (2) bedrooms, (1) bathroom, living room, program technician office and medication room. The upstairs consists of (1) bedroom, (1) bathroom, living room, kitchen and dining area. program director's office, case manager's office, therapist office and staff restroom.

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

Infection Control: Facility has an infection Control plan in place.

Operational Requirements: Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Carbon monoxide detectors were tested and operable (downstairs and upstairs). The smoke detectors were tested and operable (downstairs and upstairs). The fire extinguishers were observed and appeared to be full (last service date of 04/24/25). Hot water temperature measured at 113.9* in the bathroom downstairs and 113.3* in the bathroom upstairs. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Passageways were free of obstruction.

**Refer to LIC 809C for the continuation of this report**