Facility Evaluation Report

At approximately 1:30PM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1 year inspection and was greeted by House Manager Casey Goderum who contacted Program Director, Debbie McCulloch that arrived shortly after. 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 for the capacity of 12 Ambulatory Clients. Upon arrival, LPA was informed that there were currently 9 clients in care, although out at meetings and 4 staff members on-site.

At approximately 2:20PM, LPA reviewed the facility's staff roster with Program Director. During review, LPA discovered that Staff Member 1 (S1) was fingerprint cleared but not associated to the facility as required, but submitted required documents to CCL Office by end of inspection.

At approximately 1:45 LPA conducted a walk-though of the facility with House Manager and 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 3 bedrooms, 2 bathrooms, a kitchen, dining room, living room, and office spaces. Annex has 3 bedroom and 1 bathroom. 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. Hot water temperatures for all sinks in the facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

At approximately 2:30PM, LPA reviewed a sample size of 5 Client and 5 Staff Files. 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.