Facility Evaluation Report

At approximately 1:45 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 year visit and met with Administrator/Program Director (PD) Emily Midyette. Facility is a Long Term Social Rehabilitation home that provides care and assistance to Adults with Mental Health diagnoses. Facility has an approved fire clearance and capacity for 15 Ambulatory Clients. Upon arrival, LPA was informed that there were currently 13 Clients in care. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 2:15 PM, LPA toured the facility with Administrator Midyette. All exits were clear and unobstructed. All facility fire extinguishers were last serviced and tagged on 3/13/2025. The fire alarm system was inspected in 7/2024. Food supply was sufficient. The facility was sufficiently lighted. LPA inspected eight (8) client bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Toxins were observed to be stored inaccessible to clients. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills monthly. The last disaster drill was conducted on 3/11/2025. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational.