Facility Evaluation Report

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Clinical Director David Asch and explained the reason for the visit. Facility is a single story house with 3 bedrooms, 2 bathrooms, kitchen, dining room, living room, therapy room and a 2 car attached garage. Facility is licensed for 6 ambulatory clients. LPA and staff toured the facility. LPA observed all client rooms had the required furnishings. LPA observed an extra supply of linens stored in the hall closet. Cleaning supplies are kept locked in the garage. LPA observed a 3 day supply of emergency food and water stored in the garage. LPA observed the first aid kit had all the requirement elements. LPA observed medication and sharp objects are kept locked in a closet. LPA observed a 2 day perishable and a 7 day non-perishable food supply in the kitchen. LPA observed both bathrooms are clean and operational. Hot water measured 104.0 degrees Fahrenheit in both bathrooms. LPA observed the fire extinguisher in the kitchen is fully charged. Smoke detectors/carbon monoxide detectors tested operational. The last fire drill was conducted on June 28, 2025. There is a screened fireplace in the dining room. Staff reported the fireplace is not used. LPA and staff toured the backyard. No bodies of water observed. There is shaded seating for clients to sit outside. The exit gate is operational. No obstacles or hazards observed in the backyard. LPA reviewed 4 client files and medications, no discrepancies observed. LPA reviewed 4 staff files, no discrepancies observed. All staff members present at the facility and all staff members whose files were reviewed are background cleared and associated to the facility, LPA consulted with the Clinical Director regarding reporting requirements. No deficiencies are being cited as a result of this visit.

An exit interview was conducted and a copy of the report provided.