Facility Evaluation Report

Licensing Program Analysts (LPA) Carol Fowler arrived unannounced to conduct an Annual Required 1 Year Inspection. This facility operates as a Social Rehabilitation Facility for persons with Mental Disabilities. LPA met with Leesa Durst-Weisman, Program Manager and toured the facility.

Facility Tour: LPA toured the buildings and grounds, the facility was well lit, at comfortable temperature, with all exits free from obstructions. Bedrooms were observed to have the required furniture and linens. Hot water temperature checked between 113.5 degrees F. and within the required regulation of 105 to 120 degrees F. Fire extinguishers present on all floors last serviced 3/15/2023. The facility has a hard wired sprinkler system; smoke and carbon monoxide detectors were available and functional throughout the facility. The last disaster drill was conducted and documented on 9/14/2023 and LPA observed a fire drill during the visit. Perishable and nonperishable food supply was sufficient and met the minimum requirement. Food was observed properly stored, labeled, covered and in good condition. Medications centrally stored and locked in the medicine room. Facility has 3 floors and texts or phone calls are used for communication.

Records review: Facility staff files were reviewed. Staff have current CPR/1st aid. 5 client files were reviewed and found complete. Medication reviewed and found complete, staff provided medication count.

Licensee/Administrator to submit updates of the following documents by: 10/05/2023

Designation of Administrative Responsibility (LIC308)

No Deficiencies cited during this visit. A copy of this report provided.