Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Lead Behavioral Health Technician, Carlos Millan. LPA met with Pravesh Potla, Program Director, who arrived later during the visit.

According to the facility’s license, the facility serves as a short-term crisis residential program. The maximum capacity is six (6) ambulatory adult clients. The facility sketch was accurate to the layout of the facility. This facility does not feature a secured perimeter or delayed egress doors. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed staff and client records/files. The interviews did not raise any licensing concerns.

LPA 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 and 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’s ambient internal temperature was comfortable and recorded at 68 degrees, Fahrenheit.

LPA observed via measurement with a thermometer device that hot water temperature at taps accessible to clients were compliant: Kitchen was 113.0 and client bathroom was 111.3, degrees, Fahrenheit. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored.

Cooking/dining equipment and utensils were present. Medications were labeled, as required, and secured. Smoke alarms, carbon monoxide detectors and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. There were no sharp