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. This facility consists of the following: Downstairs- living room, kitchen, dining room, laundry room, activity room, (1) 1/2 bathroom, and an office. Upstairs- there are (3) bedrooms, (2) full baths and (1) therapist office.

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 09/30/25). Hot water temperature measured at 115.3* in the upstairs bathroom near room #3 and 117.5* in the upstairs bathroom near room #4. 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**