Facility Evaluation Report

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced required annual inspection at the facility today. LPA arrived at 10:50AM and met with staff and Primary Therapist Nicole Beatty. Entrance interview conducted. LPA, along with Primary Therapist, 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 11/11/2024. Hardwired combination smoke and carbon monoxide detectors were tested at 11:22AM and were functional at the time of the visit. Auditory exit alarms in client bedrooms and common areas were tested and functional at the time of the visit.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food and perishable food. Knives and other sharps are stored in locked kitchen drawers and cabinets. Cleaning supplies were observed locked under the kitchen sink. Foods were labeled and checked for expiration dates. There were no visible immediate hazards observed.

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 11:44AM, medications were reviewed for two (2) 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.