Facility Evaluation Report

At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Inspection and met with Staff Members, Brandon Kwok and Jacob Simon. Administrator, Charlie Litchfield, arrived during visit at approximately 9:45AM. Facility has an approved fire clearance for a total capacity of 6 ambulatory clients and provides services for adults with mental health diagnoses. Upon arrival, LPA was informed that there were currently 6 clients in care and 5 staff members on-site.

At approximately 9:30AM, LPA reviewed Facility Staff Roster and found that all staff were background cleared and associated to the facility per regulation. LPA conducted a walk-though of facility with Administrator and observed the following: Facility is a one story residence with 3 client bedrooms, 3 bathrooms, 2 office spaces, a swimming pool, and common areas. Facility has two detached offices - one is for managerial staff only and the other is designated for the facility therapists. Per Administrator, facility's swimming pool has a protective cover sheet that requires a key to operate and has two supervising staff members when clients utilize the pool. Facility has a gas fireplace located in the living room which is only intended for decor purposes. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control plan on file. Facility's hot water temperatures for all sinks were within Title 22 Regulations of 105F to 120F. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Toxins were observed to be stored in a locked closet in the living room and inaccessible to clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. All client rooms were furnished appropriately. Facility does not manage client money. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguishers were last inspected March 2025. Facility's last emergency/disaster drill was conducted December 2025. Facility has meals made off-site for lunch and dinner. Facility has a sufficient supply of perishable foods as required by Title 22 Regulations. LPA discussed increasing the amount of non-perishable foods and