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 Executive Director Carlos Montano and Director of Operations Cecilia Steinbach. The facility's license shows a maximum capacity of thirty (30) ambulatory adults. During today’s inspection, there were a total of thirty (30) clients enrolled.

LPA with Director of Operations Steinbach toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Doors, windows, screens, and toilets were in working order. Hand hygiene supplies were present. Facility does not prepare food on the premises and clients bring their own lunches. Snacks are available. The facility had sufficient space and equipment to facilitate meetings and client activities. 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 Director of Operations Steinbach, 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 kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA reviewed facility records. Review of facility records revealed that Client #1 (C1), had a sister locations residential admissions agreement on file and not this facility's admission agreement on file. Confidential records were stored in locked areas.