Facility Evaluation Report

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced required annual inspection. LPA Rodriguez explained reason for visit and was greeted and granted entry by staff on duty. During the visit, LPA Rodriguez met with Program Director (PD) Matthew Darst. LPA Rodriguez observed that current staff were background cleared and associated to the facility.

LPA Rodriguez toured the interior and exterior portions of the facility with PD. The facility is a three level structure and is licensed for 6 ambulatory clients. For this visit, there are a total of 5 clients in care, and 1 client pending admission later in the afternoon. The PUB475 "See Something, Say Something" poster was observed in the facility entry.

There are a total of 2 shared client bedrooms, and 2 client private rooms. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. There are 4 bathrooms designated for client use, 1 designated for staff, of which restrooms were observed to be in good repair, toilets were operational, and water temperature in restrooms were measured at 116.9.1 degrees Fahrenheit. There are a total of 3 staff offices (program room, medication room, clinical office).

Smoke and carbon monoxide detector were tested and operational. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients in care. LPA Rodriguez observed fire extinguishers charged, mounted, located in multiple areas of the facility and dated for 2025. LPA Rodriguez observed the emergency disaster and evacuation plan, which is posted at the entry of the facility. Facility had back-up emergency food and water supply, located in the garage and in the kitchen. LPA Rodriguez observed that the facility First Aid Kit had all the required components.