Facility Evaluation Report

At approximately 12:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit and met with Assistant Program Director, Sean Luna. Program Director, Kelsey O'Brien was available by telephone. 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 14 clients in care, and 3 staff members on-site.

At approximately 12:55PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1PM, LPA conducted a walk-though of the facility with Assistant Program Director. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. 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 and dangerous items 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 within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected October 2023 (deficiency cited, LIC809D, regulation 81020(a)(1)). Facility's smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted September 2024.

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

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page),Plan of Corrections, and Appeal Rights discussed and provided to Assistant Program Director. Signature on form confirms receipt of documents.