Beginning at 09:54AM, a tour of the physical plant was conducted to ensure client health and safety and the facility is in compliance with Title 22 regulations. The following was observed:

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient perishable food for two (2) days. During today's visit, Administrator ordered sufficient emergency food to be delivered by 05:00PM. Knives and other sharps are stored in a locked cabinet under the kitchen sink.

COMMON AREAS: These include the Family Room and Dining Room. All furniture appeared clean and in good condition. A fireplace was observed in the family room to be adequately screened at the time of the visit. Fire extinguishers were observed throughout the common areas and were last serviced on 07/10/2023. Combination smoke detectors and carbon monoxide detectors were tested at 10:19AM and were functional.

BEDROOMS: There are 4 (four) bedrooms; 2 (two) are designated for shared client use and 2 (two) are private client rooms. All bedrooms were observed to contain appropriate furniture, bedding and linens. There were no visible hazards or discrepancies observed.

BATHROOMS: There are 3 (three) bathrooms; 1 (one) is located in the hallway and is designated for shared client use, 1 (one) is a private client restroom, for use by both private client bedrooms. 1 (one) restroom is designated for staff and visitor use. All bathrooms were observed to be clean and sanitary and supplied with appropriate paper and hygiene products. Water temperature was tested in both client restrooms and measured within the required range.

SURROUNDING GROUNDS: The Front Yard includes a driveway, paved walkways and landscaped areas. The backyard is fenced and includes both paved and landscaped areas, a patio, furniture appropriate for outdoor use, shade, and an in-ground swimming pool. The pool is kept inaccessible to clients with the use of fencing that includes a locked gate. Staff have received the appropriate Water Safety Certification and Administrator stated that qualified staff are present at all times that the pool will be in use by clients. No immediate hazards were observed during the visit.

CLIENT FILE REVIEW: LPAs reviewed 2 (two) client file records during the visit. 2 of 2 client files reviewed contained all required documents.

STAFF FILE REVIEW: LPAs reviewed staff records during today's visit. All staff records reviewed were in compliance with Title 22 regulation at the time of the visit.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's infection control plan as well as the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan was observed to be complete and recently updated. The facility has yet to complete a disaster drill to date, but plans to conduct quarterly disaster drills.

MEDICATION REVIEW: LPA reviewed medications for 2 (two) clients. Both 2 (two) of 2 (two) clients' medications were stored and administered in compliance with regulation.

During today's visit, AGPA Hyde discussed with the Licensee/Administrator/Program Director the verbiage on the facility's website related to substance abuse. Licensee explained that the facility does not provide active use treatment nor detox, only mental health services to those in recovery. AGPA advised that all language related to substance use be removed from the facility's website in order to avoid confusion in the facility's programming. LPAs and LPM confirmed there is nothing in the facility's program design relating to active substance use treatment nor detox programming. During the visit, no evidence of substance use treatment or detox programming was observed.

No citations issued. Exit interview conducted. A copy of today’s reports were reviewed and provided.