Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Debbie McCulloch. Facility contact information was reviewed. Facility is a Social Rehabilitation Program for Adults with Mental Health and Substance Abuse Disorders.

At approximately 10:00am LPA and House Manager toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. LPA observed that there were two locked closets and two locked freezers located in the facility's Annex. Per Admin, these closets and freezers are used for emergency food storage and bulk item overflow. LPA confirmed that the locked closets and refrigerators store the facility's extra food and bulk supplies. Some food items stored in Annex were found to be expired: canned goods, boxed muffin mix, cereal bars, and packaged Little Debbie snack cakes. Admin discarded identified expired food items with LPA present. LPA advised Admin to do an audit of entire overflow snack and canned food storage to discard expired items. All food stored in the main building kitchen is unlocked and free for residents to use to make meals. Snacks are readily available by request and stored in staff office. Cabinet containing cleaning supplies was locked. Sharp knives locked in staff office.

All bedrooms were equipped with lighting, night stand, and chest of drawers. LPA advised each resident needs to have a lamp for use in their room. All bedrooms were clean. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care measured at 108.2, 117.3 and 106.1 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 8/9/2023. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drill was conducted on 4/9/2024. LPA advised Admin that drills need to be conducted quarterly.