Facility Evaluation Report, 07/13/2023

At approximately 2:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 year Visit and met with Program Director, Debbie McCulloch. Facility is a Social Rehabilitation Program that provides care and assistance for Adults with Mental Health and Substance Abuse Disorders. Facility has an approved fire clearance and capacity for 12 Ambulatory Clients. Upon arrival, LPA was informed that there were currently 6 clients in care and 4 staff members on-site.

At approximately 2:25PM, LPA reviewed the facility's staff roster with Program Director. During review, LPA discovered that Staff Member 1 (S1) and Staff Member 2 (S2) were fingerprint cleared, but not associated to the facility as required. LPA contacted the Regional Office and confirmed the fingerprint clearance and association statuses of S1 and S2 to the facility. Facility sent the association paperwork to the Regional Office today, 07/13/2023. LPA confirmed with the Regional Office that the paperwork had been received.

**Program Director understands that a Civil Penalty is not being issued today for S1 and S2 because their association paperwork has been received by the Regional Office to be processed.**

LPA conducted a walk-though of the facility with Program Director. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility is a one story building with an Annex attached. Main House has with 3 bedrooms, 3 bathrooms, a kitchen, dining room, living room, and office spaces. Annex has 3 bedroom and 1 bathroom. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to Clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Client use.

The facility's last fire drill was conducted May 2023. Facility's fire extinguishers were last inspected August 2022.