Facility Evaluation Report

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 06/18/2025. LPA Mosley entered the facility at 9:45 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator arrived shortly thereafter. LPA met with The Administrator / Licensee Representative / Clinical Director, Dr. Shannon Dobbs and explained the reason for the visit. Entrance interview.

The LPA and staff briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

RECORDS : At 10:17 a.m. six (6) personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. Client records review began at 11:00 a.m., one (1) current client and four (4) former client records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

MEDICATIONS : Medications review began at 11:31 a.m.; medications are centrally stored and locked in the lower level attached garage. Medications for one (1) client was reviewed. Medication/s are labeled and checked for expiration dates. All medications including PRNs are labeled, stored, and locked inaccessible to clients in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review.