Facility Evaluation Report

On 6/23/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the social rehabilitation facility to conduct a required annual inspection. LPA met with Administrator, Amber Berry and Clinical Director (CD), Holly McNerney who were informed of the purpose of LPA's visit. The facility has a fire clearance for 16 clients of which four (4) may be non-ambulatory.

LPA toured the facility with administrator and CD. During the tour, LPA observed the facility is made up of eight client bedrooms, three (3) bathrooms, a kitchen, dining room, living room and computer room available for client use. Each bedroom has two twin beds and appropriate furniture and lighting. No bodies of water were observed on the premises. Indoor and outdoor pathways were free of obstructions. Outdoor shaded seating is available for client use. The facility has a two-day supply of perishable foods and seven-day supply of non-perishable foods, which are stored in a safe and healthful manner. Medications are secured in the nurse's office. LPA observed fire alarms and sprinklers throughout the facility. LPA reviewed the facility's "Emergency Drill Assessment Tool" noting their last fire drill was conducted on 6/3/2025. LPA observed charged fire extinguishers mounted throughout the facility last serviced on 8/29/2024. LPA reviewed random digital client files, which had Departmental required records. LPA was informed the facility does not safeguard clients' cash resources. Complaint phone number, clients' personal rights, and facility sketch are posted near the entrance. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to administrator and CD.