Facility Evaluation Report

At approximately 8:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Laurie Lieberman. Team Leader, Zasha Daep, and Assistant Program Director, Suhay Rivas arrived during visit at approximately 9:20AM and 9:45AM. 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 10 Ambulatory Clients. Upon arrival, LPA were informed that there were 9 clients in care and 1 staff member on-site.

At approximately 9:00AM, 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 Team Leader, and observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 3 story building with 5 Client bedrooms, 4 bathrooms, 1 staff room, 2 staff offices, and common spaces. Facility has Infection Control Plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. 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. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Fire extinguishers were last inspected March 2026. Smoke detectors are hard wired and were last inspected March 2026. Carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted June 2026. Facility drill records showed that drills were only done on PM/evening shift. Per conversation with Team Leader, facility does not operate on a typical eight (8) hour shift schedule with AM/Morning, PM/Evening, and Night/NOC shifts. Per Team Leader, full-time staff members stay on-site for multiple days at a time and then switch. Facility's emergency disaster plan was last reviewed and updated 2026. During walkthrough, it was observed that facility did not have an adequate supply of