Facility Evaluation Report

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose to conduct the Required 1 Year Annual Inspection. LPA met with Licensee/Administrator Britten Devereux at 2:00pm and explained the reason for the visit.

This facility is located on the fourth floor of a commercial building. The facility maintains a license for an Adult Day Program (ADP) but has not actively started receiving clients. The facility currently receives patients through their Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) licensed through the California Department of Public Health and Department of Health Care Services. Patients from these programs take part in group therapy rooms. LPA conducted the tour of the facility accompanied with with the Administrator and the following was observed: There are a total of thirteen rooms dedicated to the Social Rehabilitation clients and three rooms dedicated to the ADP clients - Zen Group Room, Calm Group Room, and Office (for case management meetings). LPA also observed the mini kitchen, Staff Inventory Room, and three client bathrooms. The hot water measured at 110.6, 112.8, and 109.4 degrees Fahrenheit in the bathrooms. The two fire extinguishers were mounted, charged, and serviced by Precision Fire Systems on March 1, 2024. Facility appears clean, sanitary, and free of odors in all areas inspected. LPA observed hallways and walkways were free of obstruction. Cleaning supplies and other toxic substances are secured in the Staff Inventory Room. Facility did not maintain emergency food and water. No client files were reviewed and interviews were not conducted as the client census is zero. LPA reviewed two out of the two staff files and conducted interviews. There were no health and safety concerns observed during today's visit. The following were advised: to update and submit a copy of the Emergency Disaster Plan form (revised on 12/21) and to maintain emergency food, water, and supplies. Administrator was reminded to notify the Department when the first ADP client is admitted to the facility. Based on today's observations, no deficiency is being cited per the Title 22 Division 6 Chapter 3 of the California Code of Regulations. An exit interview was conducted with Administrator Britten Devereux, and a copy of this report and the Advisory Note were provided at the end of the visit.