Facility Evaluation Report

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue 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 7 clients in care and 2 staff members on-site.

At approximately 9:15AM, LPA conducted a walk through of the facility. Hot water temperatures for all sinks in the facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. LPA observed that there were two locked closets and two locked freezers located in the facility's Annex. Per Program Director, these closets and freezers are where they store emergency food and bulk items. All Clients have access to food, snacks, and drinks in the main house. LPA confirmed that the locked closets and freezers store the facility's extra food and bulk supplies.

LPA observed that the master bedroom located in the main house currently has 3 Clients residing in the bedroom. Title 22 Regulation states that there may be no more than 2 clients to a bedroom, unless documentation is submitted to the Department for review and approval. Per Program Director, the third bed was located in the Annex, but was moved to the master bedroom to be compliant with Department of Public Health's COVID-19 requirements. LPA and Program Director discussed submitting documentation to Community Care Licensing (CCL) for review and approval to have 3 Clients to a bedroom. Facility to relocate the third bed back to the Annex while document review is in process (See Technical Advisory 81087(e)(1).

At approximately 9:40AM, LPA reviewed a sample size of 6 Client and 6 Staff File s. Client Files were all found to be well organized, thorough and contained the required documentation. Client P&I monies were documented, secure and not commingled. Review of Staff Files indicated that staff had First Aid and CPR certification. Training for 2023 was shown to be ongoing and being conducted appropriately. 1 of 6 Staff Files were shown to not have a health screening report or TB test on file (See Technical Advisory 81066(c)(10) and 81066(c)(11).

At approximately 11:45AM, LPA reviewed a sample size of 4 Client medication records. Medication was observed to be centrally stored and secure.