The facility was last visited on 12/22/2021 for a case management visit. It is a two story building with 4 bedrooms, 5 bathrooms, central nurse station, kitchen, garage, common areas, case management room, 2 therapist rooms, pool, and outdoor areas. It has an approved fire clearance for 6 ambulatory clients. The facility uses surveillance cameras inside and outside.

Entry: Upon entry, LPA observed signs hung for the facility’s COVID policies. Staff screened LPA for infectious disease symptoms and temperature. LPA recorded contact tracing information, symptoms, temperature, and vaccination status in the visitor log. The screening station contained visitor log, digital thermometer, and hand sanitizer.

Nurse Station: Room contained client and staff records, medication, therapy space, first aid, and facility postings. All medication and records were locked. The room also serves as an office.

Bedrooms: The facility has 4 bedrooms. 2 are private and 2 are shared. Bedrooms are assigned by gender. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #2 contained a non-operational fireplace with appropriate covering.

Bathrooms: The facility has 5 bathrooms. All bathrooms were sanitary and contained liquid soap, paper towels, handwashing instruction sign, and trash cans. LPA advised to acquire trash cans with tight fitting lids as an infection control measure. LPA advised the door trim on the staff bathroom be repaired. At 12:34 p.m. LPA measured the water temperature in the staff bathroom to be 107.7 degrees Fahrenheit.

Laundry: LPA and staff entered the garage and observed extra water, food, PPE, and first aid supplies. After walking up steps with non-skid strips, LPA and staff arrived at the laundry room. The laundry room was locked by a number pad on the handle. All detergent inside was locked as well. LPA observed a washer and dryer in good condition.

Common Areas: Walls, floors, ceilings, windows, and screens were clean and in good repair. Seating was arranged to provide physical distancing. LPA observed activities, a billiards table, board games, books, and art supplies in the living room and dining area. Postings for daily schedules, weekly schedules, personal rights, emergency contacts, confidential complaints, and ombudsman contacts were posted. At 12:06 a.m. LPA measured the room temperature to be 68 degrees Fahrenheit.

Case Management Room: LPA observed a therapist, a dog, and a client in the case management room. The room contained activities and instructional material.

Safety: All emergency exit paths were unlocked and free from obstructions. 3 out of 3 exit doors were unlocked. Emergency Disaster Plan posted at the front. Emergency exits maps were posted throughout the facility. At 12:37 p.m. LPA observed the 2022 smoke detector test log. 10 out of 10 facility smoke detectors were tested each month and operational. Fire extinguisher monthly tests were also recorded. At approximately 11:50 LPA observed 3 fully charged fire extinguishers in the nurse room and by bedrooms.

Outdoor areas: The facility has fitness equipment out front of the main entrance. Stairs with non-skid strips led down to a fenced and locked pool area. LPA observed pool rules hung on the gate. All areas were clean and free from hazards. Furniture was in good condition.

During today's inspection, the facility is in compliance with Title 22 regulations.

Exit interview conducted. Copy of report provided.