Facility Evaluation Report

At approximately 10:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Terry Keady. Program Director, John Ahrens, arrived during visit at approximately 11:10AM. Assistant Program Director, Suhay Rivas, arrived during visit at approximately 1:00PM. Facility is an Adult Residential Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance and capacity for 8 Clients where 1 client can be Non-Ambulatory. Per fire clearance, the Non-Ambulatory room is located in the bedroom closest to the recreation room. Upon arrival, LPA was informed there were 8 clients in care and 1 staff member on site.

At approximately 11:20AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Program Director. LPA observed the following: Facility was at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a single floor building, with 4 client bedrooms, 3 bathrooms, a staff bedroom/bathroom, 1 office space, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Toxins were observed to be stored inaccessible to clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected April 2025.

Facility's sprinkler system was inspected April 2025. Facility's last emergency/disaster drill was conducted July 2025. LPA reviewed staff files and client files. Administrator's Certificate for John Ahrens (7031309735) is current with an expiration date of 07/16/2027.

LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Exit interview conducted. Copy of report discussed and provided to Assistant Program Director. Signature on form confirms receipt of documents.