Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 01/27/2023 to conduct a required 1 - year inspection. This inspection is focused on the infection control practices and procedures of this care facility. LPA met with House Manager, Sheri Koutnik. Clients were not present during inspection, they were attending day programs.

LPA toured building and grounds which were clean and in good repair. Exits and walkways were clear from obstructions. COVID postings and screening materials were present at the front entrance as well as throughout the facility. High touch surface areas are disinfected daily. Facility has a sufficient amount of perishable and nonperishable food. Sufficient personal protective equipment was available to support a client in isolation. Toxins were locked and secured. Medications were locked and secured. Fire extinguishers were charged and current. Staff and clients are fully vaccinated.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 308 Designation of Facility Responsibility

LIC 400 Affidavit regarding client cash resources

Exit interview conducted with house manager and a copy of this report emailed to the facility. No deficiencies cited during today's inspection.