Facility Evaluation Report

At 8:45 AM License Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1-year inspection of facility. Facility Program Director (PD) Laurel Pope arrived at 9:00 AM. The facility has an approved fire clearance for ten (10) ambulatory clients. The facility is a one (1) story ranch house. There are seven (7) clients currently at the facility. This social rehabilitation facility is a 28-day program designed to provide transition and stabilizing services to adult clients. LPA reviewed the Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation.

At approximately 9:15 AM, LPA toured the facility with PD Pope. All exits were clear and unobstructed. All three (3) fire extinguishers were last serviced and tagged on 9/9/2025. The fire alarm and sprinkler system was inspected in 5/2025. The facility was sufficiently lighted. LPA inspected four (4) 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 9/14/2025. 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.