Facility Evaluation Report

Licensing Program Analyst (LPA), Alviso arrived to conduct a case management inspection, on 6/19/2025 at approximately 9:50am, and met with Lead Judy Columbo, Licensed Psychiatric Technician (LPT). LPT Judy is the back-up Administrator when needed. Currently LPT Judy is covering administrator position while Administrator Susan Webster is on leave for approximately a month's time.

This case management is being conducted to review facility operations, including review of facility's compliance plan currently in place. Facility was placed on a compliance plan for 2 yea rs on 6/29/23. Part of the compliance plan is additional monitoring inspection visits during the two years, to ensure required compliance with regulations/the compliance plan.

Facility is fire cleared for four(4) non-ambulatory, of which four(4) may be bedridden. There are four(4) clients in care. One(1) of the four(4) clients attends day program. Facility has a required infection control plan. Facility has a required emergency disaster plan.

LPA reviewed four (4) client files. Client files are complete. LPA reviewed five (5) staff files. Staff had required first aid, CPR, personal rights training, and emergency disaster training as required. Staff have training, including refresher training's completed monthly per review of facility records. Facility has reported incidents and facility information as required by regulations, per review of records.

LPA toured the facility, including outside grounds. All exits were free and clear of obstruction. The LPA observed the new flooring that was recently completed in the facility. Bathrooms were clean and orderly. Sufficient furnishings for client use. Outside seating, including shade areas for client use. Facility was at a comfortable temperature for clients in care. There were no observed concerns and/or safety hazards during the inspection.

There are no deficiencies cited during today's inspection.