Facility Evaluation Report

Licensing Program Analyst (LPA) Michelle Reed conducted an unannounced visit to the facility to conduct a Required 1 Year visit. The facility is licensed as a Crisis Residential Program with an average stay of 21 days. Upon arrival, LPA met with Ryan West. (COVID-19) screening procedures were conducted. There are currently no active COVID-19 cases in the facility. The facility staff screen and document temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The facility had an on-site program certification review by the Department of Health Care Services on 9/15/22 and found to be within compliance

At 1:15pm, LPA conducted a tour of the physical plant with Ryan West. The visit focused primarily on Infection Control. There were 13 clients present. .The facility is a two story building. There are 4 resident bedrooms downstairs and 4 upstairs. There are 4 bathrooms/showers for resident use. The facility also has a living room, dining area, kitchen, two activity rooms, 5 offices, and a laundry room and medication room. The client bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. Client bath towels and personal hygiene supplies were adequately stocked including toilet paper, paper towels and hand soaps.