Facility Evaluation Report

Licensing Program Analyst (LPA) Noel Wolf Petersen, arrived unanounced to conduct a case managment inspection at 8:00 am on 7/23/25. LPA met with Staff Gerardo verela and Adminitrator alexandria Archangel, and explained the purpose of the visit.

Physical Plant was inspected including but not limited to the kitchen, common areas, the client bedrooms, client bathrooms, exterior and evacuation route. the Facility is clean and the traffic areas are well lit and unobstructed. the Kitchen has lockable storage the sharps and toxics, as well as the 2 days of perishible/7days of non perishable food. The MARs are up to date and reflected accurately in kind and amount. the Common areas are in good repair, the clients have reasonable and privite access to an telephone and internet accessible device. the client bedrooms are in good repair, excepting bedroom 11. the administrator provided there is an active process of repair, no clients are allowed to stay in the room. Bathroom hardware is functional, water temperature is measured within the required range. The required posters: personal rights, federal work requirements, the facility sketch with evacuation routes, and ombudsman on the wall. The fire extinguishers are dated 7/2/25.

During a facility visit on 7/23/25 LPA observed, documented, and discussed with Alexandria Archangel the facilitys practice of reward tiers, which was deacribed as a level one or level 2 which allwd additional smoke breaks or freedom to leave the facility, including overnight passes if the clients particpates in group therapy sessions. these practices are not part of the facilites Plan of Operation and are a violation of a residents personal rights. Citations are issued on the 809D page related to this.

A copy of the appeal rights was given, a copy of the report was read and given to the administrator.