Facility Evaluation Report

01/07/2025 at approximately 1:40pm, Licensing Program Analyst (LPA) Loera arrived unannounced to continue an Annual Required inspection that was initiated on 12/19/2024, and was greeted by William Gavgavian, Mental Health Counselor/staff. House Manager, Jacquie Burns was unable to attend during inspection.

LPA and staff toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled. Extra food storage is located in the basement.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 118.4 and 117.2 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 01/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were located in the hallway closet and in a drawer in the kitchen and found to be locked/secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Facility conducts monthly emergency/fire drills with the last one being conducted 12/30/2024.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

Emergency Disaster Plan (review, update if needed)

Infection Control Plan (review, update if needed)

Exit interview conducted with Staff and a copy of this report was provided .