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25 | At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a 1-Year Required Visit and met with Staff Members, Sophie Phillips, Paris Watson, and Jerry Omara. Program Director, Kelsey O'Brien arrived during visit at approximately 11:40AM. Facility is a Social Rehabilitation Program that provides care and assistance for Adults with Mental Health. Facility has an approved fire clearance and capacity for 16 Ambulatory clients. Upon arrival, LPA was informed that there were 14 clients in care, and 3 staff members on-site.
At approximately 9:15AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed staff files, client files, and client medication. Staff files had current First Aid and CPR certification. Client files were found to be well organized, thorough and contained the required documentation. Client medications were centrally stored and secure.
LPA cleared deficiency that was cited during visit conducted on 11/21/2024. Plan of Corrections Letter provided.
LPA is requesting the following documents to update the facility file:
- Designation of Facility Responsibility (LIC308)
- Emergency Disaster Plan (LIC610D)
- Updated Personnel Report (LIC500)
- Register of Clients/Residents (LIC9020)
Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 04/21/2025.
No Deficiencies Cited during visit.
Exit interview conducted. Copy of report discussed and provided to Program Director. Signature on form confirms receipt of documents. |