Facility Evaluation Report

At approximately 9:15AM, Licensing Program Analyst (LPA) Felias and Investigations Branch (IB) Investigator Walter Crockett arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Stephanie Neher, and Residential Manager, Graham Malcolm-Wium . 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 9:35AM, LPA reviewed the Facility's Staff Roster found that all staff members on-site were background cleared and associated to the facility as required. LPA conducted a walk-though of the facility with Residential Manager, observed the following: Facility was at a comfortable temperature with all exits were 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 7 facility sinks were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected January 2025. Facility sprinkler system was last inspected August 2025. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted August 2025.

LPA reviewed staff files and client files. LPA also reviewed incident reports submitted to Community Care Licensing (CCL). LPA requested for additional documentation related to incidents.

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

No Deficiencies Cited during Visit. Exit interview conducted. Copy of report discussed and provided to Residential Manager. Signature on form confirms receipt of documents.