Facility Evaluation Report

Licensing Program Analyst (LPA) KaSandra Lopez arrived at the facility announced at 1:00 PM to conduct a pre-licensing inspection. The LPA met with Regional Vice President Emily Eckstien, Administrator and Program DIrector Deanna Woodhouse , Program Manager Allison Prather, and Director of Clinical Operations, Yvette Llanos The fire clearance was granted on 01/05/2023 for six ambulatory clients only. Component III was completed during today’s visit.

The LPA toured the single-story home inside and outside with applicants to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations and the Health and Safety Code.

COMMON AREA: The facility common areas includes the group therapy room, kitchen, formal dining room, family room, nursing office, therapy office, and staff office in the garage. The common areas were appropriately furnished, and the lighting was adequate. The facility has a central entry point for symptom screening and sanitation station for staff, clients and visitors. There was a fireplace in the family room which is properly screened. The facility smoke alarm system is hard wired; the combination smoke detectors/carbon monoxide detectors were tested and were operable at the time of the visit. There are three fire extinguishers in the home. Proof the fire extinguishers were purchased or serviced within the last year needs to be provided. There was a functioning telephone on the premises. Cleaning supplies and hygiene items are stored in a locked cabinet in the hallway. Facility had a sufficient supply of towels and linens. Emergency exiting plans/sketch were posted throughout the facility.

BEDROOMS : The facility designated three (3) bedrooms for client use. Each bedroom has two beds, night stands, chairs, and lights. Bedroom #1 has a screened fire place. Bedroom # 1's closet does not currently allow for clothing to be hung and Bedroom #2 is missing a minimum of two drawers or eight cubic feet for each client.

MEDICATIONS : Medications will be kept locked and inaccessible in a medication cart in the nursing office. First aid supplies were reviewed and are complete. The facility has a sufficient supply of personal protective equipment and a plan in place if an isolation room is needed. Report continued on LIC 809-C.