Facility Evaluation Report

At approximately 12:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Administrator, Heather Deghi. Facility serves clients with mental health diagnoses. Facility has an approved fire clearance and capacity for 10 ambulatory clients. Upon arrival, LPA was informed that there were 10 clients in care with all clients out of the facility. LPA was also informed that there was 1 staff member on-site.

At approximately 12:55PM, 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 1:00PM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 6 client bedrooms, two bathrooms, and common spaces. Facility has an Infection Control plan on file. 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. Mattress pads were in place or available for client use. Toxins were observed to be stored inaccessible to clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

At approximately 1:15PM, LPA reviewed staff files, client files, client medication, and client P&I monies. All files were all found to be well organized, thorough, and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. P&I monies were documented, secure and not commingled. Administrator's Certificate for Heather Deghi (6019700735) was current with an expiration date of 08/22/2024.

Fire extinguishers were last inspected February 2024. Carbon monoxide detectors were tested and operational. Facility has a hard wired system for smoke and fire that was last inspected November 2023. The last facility fire/disaster drill was conducted in December 2023.