Facility Evaluation Report

On 7/11/25 at 9:30 am, Licensing Program Analyst(LPA) Noel Wolf Petersen arrived at the facility to conduct a case management associate with an incident, LPA met with Interim Program Director, Donna Colbert and explained the purpose of the visit.

The Physical plant was inspected including but not limited to the client bedrooms, bathrooms, the storage areas, common areas, hallways, exterior, and evacuation routes. The facility is clean and traffic areas are well lit and unobstructed.

The incident is regarding a substance that entered the facility, a client taking the substance and seemingly requiring narcan intervention, and then a fellow client administering the narcan rather than a staff. This is the facilities first incident of this kind, drug use at the facility resulting in narcan administration, the facility is going to make updates to the program design and admission agreement to better address the supervision concerns around entrance of matierals into the facility and stricter monitoring of the clients, as well as training of the staff on likely emergency medical intervention (how to administer narcan for emergency use). The updated policies and procedures will be part of the Plan of Correction associated with the citation.

Per Title 22, citations were issued as a part of visit. Appeal rights were provided.

A copy of the report was read and given to the administrator.