Facility Evaluation Report

Licensing Program Analysts (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Cemi Smith, Staff and Program Manager Monica McDade arrived during the visit.

According to the facility’s license, the facility has a maximum capacity of 6 ambulatory clients, age range from 18 to 59. There are a total of 5 clients currently residing at the facility. During today’s inspection, 3 clients were at Day Program. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by the staff Cemi, 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, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 73 F. Hot water temperature at taps accessible to clients were not compliant: Bathroom #1 sink was 126.6 F, and Bathroom #2 sink was 136.6 F. Bathroom #3 was locked and inaccessible due to the grout drying around the new shower doors that were recently put up.

No pools or bodies of water were observed on the premises. Per Program Manager Monica McDade, there are no firearms or ammunition kept at the facility. Smoke alarms, carbon monoxide detectors and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Required licensing postings were observed in visible areas of the facility.