Facility Evaluation Report

Licensing Program Analysts (LPAs) Valeria Conway, Brittany Thomas and Kelly Dulek conducted an unannounced Annual Inspection at the facility today. LPAs arrived at 01:47PM and met with facility Administrator/Program Director Paul Figueroa. Entrance interview conducted.

LPAs, along with Administrator, toured the facility beginning at 01:54PM to ensure client health and safety and the facility is in compliance with Title 22 regulations. The following was observed:

Hardwired combination smoke and carbon monoxide detectors were tested at 02:32PM and were functional at the time of the visit. Fire extinguishers were observed throughout the common areas, and were fully charged and last serviced 11/15/2023.

COMMON AREAS: The facility is a 2-story home, consisting of an upstairs and a downstairs area. There are no common areas upstairs. Downstairs common areas include a living room, study, and dining area. All furniture appeared clean and in good condition. A dual-sided fireplace in the study/dining room, and separate fireplace were observed in the living room and an additional fireplace in the upstairs office; all fireplaces were observed to be adequately screened at the time of the visit.

TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: Upstairs rooms were observed to remain locked at all times, and accessible to clients when they are with staff. Upstairs consists of 2 office areas and a group therapy room. Downstairs contains a locked nurse/staff office, which contained a locked medication closet. At 03:38PM, medications were reviewed for 2 (two) clients. Medications observed were properly labeled and medication records observed were documented per regulation. The First Aid Kit is stored in the Medication Room and was observed to be complete. The Offices are kept inaccessible to clients unless properly supervised.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food Report Continued on LIC 809-C