Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced for a required one year visit. The LPA met with Program Director Rebekah Sanchez Norton and explained the reason for the visit. The LPA toured the physical plant to ensure there were no health and safety hazards.

KITCHEN : Knives and chemicals were kept inaccessible. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. BEDROOMS : The shared client bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted. RESTROOMS : Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 12:55 p.m., water temperature in the common hallway bathroom measured at 106.5 F. Restrooms were fully stocked. Hand-washing signs were observed in all restrooms.

COMMON SPACES : Smoke and common monoxide detectors were tested at 12:42 p.m. and were operable. Medications were locked and inaccessible in the staff room. Fire extinguishers were charged and serviced 3/2022. The backyard had furniture and a covered area for client use. There was a water feature (waterfall) however, water rises at less than an inch and meets the level of the rocks. The side gate was self-latching.

THERAPY AND STAFF: The LPA observed the Isolation Room and Recreational room on the ground level, the Activity Rooms, and a Staff Room on the first floor, and the small therapy room on the second floor. The above-mentioned rooms can be utilized for individual and group therapy. Files are stored inaccessible.

INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. The facility’s cleaning protocol was sufficient. There was record of staff and client vaccinations. The staff are up to date regarding testing, visitation and vaccine requirements. Personal Protection Equipment (PPE) supply was adequate. The facility's procedures as it pertains to infection control are adequate.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.