Facility Evaluation Report

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to staff Olivia Cabo and Alleyne Ortiz. Program Director Kendahl Meno arrived later during the visit, as well as Lead Clinician Madison Gebhardt, Executive Director (ED) Anthony Guerena, Program Administrator Alexa Pina, and Health Services Director Audrey Steinbach. The facility's license shows a maximum capacity of six (6) ambulatory clients. Per the facility's fire inspection report, downstairs bedrooms are for clients and upstairs designated for office space. During today’s inspection there were five (5) clients in care.

LPA, Program Director Meno, Health Services Director Steinbach, ED Guerena, Lead Clinician Gebhardt, and Program Administrator Pina toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were initially not all compliant: Common bathroom sink was 98.2F. Upstairs staff restroom also read at 98F and a Technical Violation (TV) was issued. Staff were able to adjust the water heater to compliant range during LPA's visit and temperature now measured at 108.5F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to clients in care.