Facility Evaluation Report

At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit and met with Program Director, Riley Reck. Facility is a Social Rehabilitation Program that provides care and assistance for Adults with Mental Health. Facility has an approved fire clearance and capacity for 16 Ambulatory clients. Upon arrival, LPA was informed that there were 13 clients in care, and 6 staff members on-site.

At approximately 10:00AM, LPA reviewed the facility's staff roster with Program Director. During review, LPA discovered that Staff Member 1 (S1 ) was fingerprint cleared, but not associated to the facility as required. LPA contacted the Regional Office and confirmed the fingerprint clearance and association status of S1. Facility associated S1 during LPA's visit.

**Program Director understands that a Civil Penalty is not being issued today for S1 because they were associated during LPA's visit.**

At approximately 10:30AM, LPA conducted a walk-though of the facility with Program Director. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility is a one story building with 8 bedrooms, 4 1/2 bathrooms, common areas and staff offices. 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. During walk through, LPA observed 2 of 7 sinks were out of compliance with Title 22 Regulations measuring at 122.3F and 121.2F (Technical Violation issued, See LIC9102, Regulation 81088(e)(1)). Per conversation with Program Director, all clients are independent of their Activities of Daily Living (ADLs) and do not have diagnoses of dementia.

LPA observed Client 1 (C1) using a cane while at the facility. Per their physician's report, they have an ambulatory status. LPA informed Program Director that if C1 becomes non-ambulatory and needs an walking device such as a wheelchair or a walker, then an updated Physician's Report will be needed, as well as an updated Fire Clearance and sketch.

Facility has three fire extinguishers which were last inspected April 2022. Facility immediately contacted a vendor to inspect the extinguishers so they are updated appropriately (This deficiency has been cited, see LIC-809D, Regulation 81020(a)(1)).