Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Annual Inspection at the facility today. LPA arrived at 09:38AM and met with Program Manager Joseph Raya-Ward. Entrance interview conducted.

LPA, along with Program Manager, toured the facility to ensure client health and safety and the facility is in compliance with Title 22 regulations. The following was observed:

Fire extinguishers were observed to be fully charged and last serviced 11/16/2023. Hardwired combination smoke and carbon monoxide detectors were tested and were functional at the time of the visit.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food to accommodate clients for 7 (seven) days and perishable food for 2 (two) days. Knives and other sharps are stored in locked kitchen drawers and cabinets. Cleaning supplies were observed locked under the kitchen sink. There were no visible immediate hazards observed.

COMMON AREAS: The facility consists of 3 stories - the entry level and two lower levels. There are common areas found on each of the 3 (three) levels, including a Dining Room, living room, Art Room, and sitting area. All furniture appeared clean and in good condition.

TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: There is a Group Room, Staff Office and Nurse's Office/Medication Room on the entry level. The medication room was observed to be locked and contains a locked medication cart. At 12:44PM, medications were reviewed for 2 (two) clients. Medications observed were properly labeled and medication records observed were documented per regulation. The First Aid Kit is stored in the Medication Room and was observed to be complete. The ground floor also contains an individual therapy room. The Offices are kept inaccessible to clients unless properly supervised.