Facility Evaluation Report

At approximately 9:40AM, Licensing Program Analysts (LPAs) Felias and Stevenson arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Charles Boomer, and House Manager, John Coleman. Facility is an Adult Residential Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance for 6 Ambulatory Clients and 2 Non-Ambulatory Clients for a total capacity of 8 clients. Upon arrival, LPAs was informed there were 8 clients in care and 3 staff members on-site.

At approximately 9:55AM, LPAs 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 10:10AM, LPAs conducted a walk-though of the facility with House Manager. LPAs observed the following: Facility was at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 2 story building with 4 client bedrooms, 3 client bathrooms, a staff room, an office, and common spaces. 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 and other dangerous items were observed to be stored inaccessible to clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. 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 January 2024. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted September 2024.

LPAs reviewed staff and client files. Staff files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. During client record review, LPAs observed that 3 of 4 clients did not have an updated needs and services plan, and 4 of 4 clients did not have signed personal rights (deficiency cited, LIC809D, Regulation 81070(b)). Administrator's Certificate for John Coleman (7017939735) is current with an expiration date of 01/06/2025.

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