Facility Evaluation Report

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Stephanie Neher. Program Manager, Hope Hurst, arrived during visit at approximately 10:15AM. Facility is a Long Term Social Rehabilitation Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed there were 6 clients in care and 7 staff members on site.

At approximately 9:45AM, LPA reviewed the Facility's Staff Roster found that Staff Members 1 and 2 (S1 and S2) were not fingerprint cleared or associated to the facility as required. LPA also observed that Staff Member 3 (S3) was not associated to the facility as required. LPA notified S1 and S2 to leave the premises and saw that S3 was associated to the facility during visit (deficiency cited and civil penalty issued, see LIC809D and LIC421BG, Health and Safety Code 1522(c)(1)). At approximately 11:45AM, LPA conducted a walk-though of the facility with Staff Member, Kimeeco Epps. LPA observed the following: Facility was at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. 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. A sample size of 5 sinks were tested for hot water temperature. 4 of 5 sinks were within Title 22 regulations of 105 to 120 degrees Fahrenheit (see technical advisory, LIC9102, regulation 81088(e)(1)) and 1 of 5 sinks was found to be at 104.9F. Facility's fire extinguishers and sprinkler system were last inspected January 2024. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted September 2024.

During walkthrough, LPA observed that the facility had converted a staff office and a double occupancy room into two single occupancy rooms. The facility previously had 3 shared client bedrooms for a total capacity of 6 clients. Facility now has two single client bedrooms, and two shared client bedrooms. Licensee to submit an updated facility sketch to indicate the changes made by 10/04/2024.