KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food to accommodate clients for (seven) 7 days and perishable food for two (2) days. Management indicated lunch and dinner are catered and the clients eat out on the weekends. Clients prepare their own breakfast foods. There were no visible immediate hazards observed.

BEDROOMS: There are four (4) Bedrooms, three (3) of which are designated for shared client use. The fourth bedroom is located on the first floor and is designated as an isolation room, as needed for infection control purposes. The three (3) shared client rooms are on the second floor. All client bedrooms were observed to contain appropriate furniture, bedding and linens.

BATHROOMS: There are four (4) full bathrooms and one (1) half bath. Three (3) full baths are designated for client use and one (1) is designated as the isolation room bathroom. The half bath is designated for staff and visitors. All bathrooms had functional fixtures and contained all required supplies. All bathrooms were supplied with appropriate paper and hygiene products. Water temperature was measured in client restrooms and measured within the required range. Report Continued on LIC 809-C

COMMON AREAS: These included two (2) Living Rooms, the Dining area, and an activity room. All common areas appeared to be clean and were appropriately furnished. Knives and other sharps are stored in a locked closet. There were no visible hazards.

TREATMENT/THERAPY & OFFICE AREAS: There is a group therapy room, an individual therapy room and an office designated for Staff use, which is used to store medications as well as first aid kit, on the first floor. The Offices are kept inaccessible to clients unless properly supervised. There is a small group room on the second floor. The above-mentioned rooms can be utilized for individual and group therapy.

GARAGE AND GROUNDS: The garage is designated as the Recreational Room. The garage is used as an activity and group room/gym as well as to store emergency food and water and additional supplies. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs where clients can sit. There is a storage shed in the backyard. There is an in-ground pool, which is kept locked and is appropriately fenced per regulation. There were no imminent or immediate visible hazards.

STAFF/CLIENT FILE REVIEW: Staff and client files are stored electronically, however the facility also has physical client files. Beginning at 10:42AM, LPA reviewed four (4) out of four (4) client files. LPA reviewed four (4) staff files at 11:14AM. All staff and client records reviewed were in compliance with Title 22 regulations at the time of the visit.

MEDICATION REVIEW: Beginning at 11:03AM, LPA reviewed medications for two (2) clients. All medications observed were documented and stored in compliance with regulation at this time.

INFECTION CONTROL/DISASTER PREPAREDNESS: During today’s visit, LPA reviewed the facility's infection control policy and disaster preparedness policies. All items reviewed were in compliance. The facility conducts emergency disaster drills quarterly, with the most recent drill documented on 12/26/2024.

No citations issued. Exit interview conducted. A copy of the report was provided.