Facility Evaluation Report

At 9:15 AM License Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1-year inspection of facility. LPA was welcomed by Mental Health Counselor (MHC) Elizabeth Roggeveen and Case Manager (CM) Elissa Gensburg. There are nine clients currently at the facility. This social rehabilitation facility is a 28-day program designed to provide transition and stabilizing services to adult clients. LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. Administrator/Program Director Cedric Jackson was not at the facility during the inspection.

At 10:00 AM, LPA began the facility tour with MHC Roggeveen. Random bedrooms inspected had appropriate furnishings per Title 22 Regulations. There are two bathrooms for clients that were inspected. The hot water temperature in client’s bathrooms measured between at 105 degrees F and 120 degrees F within Title 22 regulations. LPA observed that two (2) of two (2) clients' bathrooms did not have waste receptacles with tight fitting covers. A Technical Violation (TV) was issued for the waste receptacles not being in compliance. Toxic cleaning supplies are stored in a locked closet located in the laundry room. Perishable and nonperishable food supplies were sufficient to Title 22 Regulations of 2 days of perishable and 7 days of nonperishable. Knives are kept locked in drawer in staff office area. The kitchen and dining area was organized and free of clutter. The facility is well lit and at a comfortable temperature. The facility was clean and well maintained, with housecleaning service conducting a once a month deep clean. During the month a sign up sheet for house chores/cleaning is filled in by clients to complete and those not are done by clients are completed by staff. There is a large multipurpose room used for client meeting and activities. A large seating area where clients may congregate, or staff are able to hold group meetings is located off the kitchen/dining area. During the facility tour Team Leader (TL) Balakimwe Farara arrived at the facility.

The facility has a locked medication room. Medications are stored in a locked cabinet within the room. There is also a metal locked box stored within the medication cabinet for any medication that requires a third lock.