Facility Evaluation Report

At approximately 9:05 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required Visit and was greeted by Program Director (PD), Matthew Long. The facility provides social rehabilitation for adults. Facility is a single story ranch house with a detached garage. There are several outside seating areas and a small pond which is secured behind a wooden fence. Facility has an approved fire clearance for twelve (12) ambulatory clients. Upon arrival, LPA was informed that there were ten (10) clients in care and four (4) staff members on-site. At approximately 9:30 AM, 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 10:00 AM, LPA toured the facility with PD Long. All exits were clear and unobstructed. All three (3) fire extinguishers were last serviced and tagged in July, 2024. Fire Department inspected and cleared the fire alarm system in July, 2024. Food supply was sufficient. During Inspection, LPA observed two (2) cans of food that had expired. A Technical Violation was issued for the two (2) cans of food that had expired. The facility was sufficiently lighted and Furnished. LPA inspected three (3) 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 1/23/2025. 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 operational.