Facility Evaluation Report

At approximately 1:25PM, Licensing Program Analysts (LPAs) Felias and Stevenson arrived unannounced to continue a Required 1 Year visit and met with Staff Member, Charles Boomer, and House Manager/Administrator, 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 2 staff members on-site.

At approximately 1:35PM, LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs reviewed client medication. Medication was centrally stored and secure. During visit, House Manager/Administrator informed LPAs of an incident that occurred on 01/05/2025. Per discussion with Administrator, Client 1 (C1) had a fall which resulted in an shoulder fracture. House Manager/Administrator was able to provide a copy of the completed incident report to LPAs but was unable to provide proof that it had been submitted to the Department within the required timeframe. LPAs reviewed reporting requirement regulation with facility (technical violation issued, LIC9102, regulation 81061(b)(1)(D)). Per Administrator and Facility Staff, C1's care is being re-assessed.

LPAs requested the following documents to update facility file:

Designation of Facility Responsibility (LIC 308)

Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of 2/21/2025.

Exit interview conducted. Copy of report, LIC9102 (Technical Advisories/Violations), and LIC811 (Confidential Names) discussed and provided to House Manager/Administrator. Signature on form confirms receipt of documents.