Facility Evaluation Report

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Client Coordinator Julie Mullen. Executive Director Anad Mehta and Clinical Director Kristian Concepcion arrived during the visit. The facility's license shows a maximum capacity of six (6) ambulatory adults. During today’s inspection there were 5 clients in care.

LPA with Client Coordinator Mullen toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Client Coordinator Mullen, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas.

No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Mehta and Clinical Director Concepcion to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.