Facility Evaluation Report

On 9/11/2024, Licensing Program Analyst's (LPA's) Jenifer Tirre and William Venagas conducted an unannounced required visit using the CARE Inspection Tool. LPA's were greeted by staff and granted entry after stating the purpose of the visit. Chief Strategy Officer Shahan Suzemeyan and Director of Operations Bryan Johnson was present to assist with the facility inspection on today's date.

The facility is licensed for six (6) ambulatory clients. Facility is a Short Term Crisis Residential Treatment Program for a Social Rehab.

This is a three story with a two-car garage facility. The facility has three shared Client bedrooms, one staff office, three full bathrooms and one half bathrooms.

Upon arrival LPA's conducted Client interviews due to clients heading out to group activity, At 8:30 LPA's conducted a tour of the physical plant accompanied by Director of Operations, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were operational with water temperature measured between 108.2 to 117.1 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility.

LPA's observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, toxins and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility fire extinguishers were fully charged and mounted. Facility has three extinguishers. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.