Facility Evaluation Report

Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced annual inspection focusing primarily on the Infection Control. LPA was greeted and granted entry by Behavioral Health Tech (BHT) Grecia Taylor. LPA stated the purpose of the visit and entered the facility at 10:16 am after completing the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases in the facility. LPA observed that facility screened and documented temperatures for visitors in the entryway. The required COVID-19 precautionary signs were posted on the front door and the entryway.

Around 10:25 am, LPA and BHT Taylor toured the interior and exterior portions of the facility. Supervisor Ramen Carpenter assisted the tour around 10:40 am. The facility is a single level structure and licensed for six ambulatory clients. As of today, there were five clients in the facility. LPA observed four clients at the dining table and one client resting in the bedroom. Facility appeared clean and sanitary in all observed areas. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxides tested operational. Restrooms observed to be in good repair; and provided with a grab bar and a non-skid floor mat. Facility had the required hand washing signs posted in all the restrooms and provided hand soaps and paper towels. Hot water measured at 109.5 degrees Fahrenheit in Restroom #1 and 110.8 degrees Fahrenheit in Restroom #2. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the clients in care. The three fire extinguishers were mounted of which one was not charged. In addition, the three fire extinguishers were last serviced on 3/8/2021 and exceeded their annual inspection date. The fire extinguishers were purchased from Home Depot and were replaced during the visit. For the exterior portion, the facility had an outdoor visitation area with a patio furniture under ample shading, and grounds were free of tripping hazards. The side gates were self-closing and self-latching. LPA observed the incorrect LIC610 Emergency Disaster for Child Care Centers dated 2/19/2021 was used instead of the LIC610D Emergency Disaster Plan for Social Rehabilitation Facilities.