LPA toured the facility beginning at 9:45 a.m. to ensure client health and safety and the facility is in compliance with Title 22 regulations. Fire extinguishers were last serviced on 4/27/2024 and appeared fully charged. The smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire department last inspected the facility in September 2023.

COMMON AREAS: These include the family room, dining room, and gym. All furniture appeared clean and in good condition. A fireplace was observed in the family room to be adequately screened.

TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: There is a family room, therapy room, medication room, and two offices on the ground floor. There is a learning lab with six computers that have Internet access and a therapy room located on the second floor. Medications are stored in a locked first floor medication room which has adequate locked storage, including a locked refrigerator. Medications were reviewed for two clients. Medications were properly labeled, records were documented per regulation and appeared to be given as prescribed. The first aid kit was observed to be complete. The medication room and offices are kept inaccessible to clients unless properly supervised.

LAUNDRY: The locked laundry room is located on the ground floor. Laundry and cleaning supplies were observed to be inside a locked closet in the locked laundry room.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food to accommodate clients for seven days and perishable food for two days. Staff stated lunch and dinner

Report Continued on LIC 809-C

BEDROOMS: There are three bedrooms, all of which are designated for shared client use. All bedrooms are located on the second story and were observed to contain appropriate furniture, bedding and linens. There were no visible hazards observed.

BATHROOMS: There are five bathrooms. Two bathrooms on the ground floor and three on the second floor. The bathrooms located on the ground floor include a full bath attached to the office designated for client use and a half bath in the main hallway for staff use. The bathrooms located on the second floor are all full bathrooms and two are designated for client use and one for staff use only. All bathrooms were supplied with appropriate paper and hygiene products. The hot water temperatures ranged from 107.3-108.1 degrees Fahrenheit.

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, an in-ground swimming pool, a stable and locked barn. 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 Designee stated that qualified staff are present at all times that the pool is in use by clients. No immediate hazards were observed during the visit.

STAFF/CLIENT FILE REVIEW: LPA reviewed five staff and four client files during the visit. All staff and client records reviewed were in compliance with Title 22 regulation at the time of the visit.

INFECTION CONTROL/DISASTER PREPAREDNESS: During today’s visit, the LPA reviewed the facility's infection control policy and disaster preparedness policies. All items reviewed were in compliance.

INTERVIEWS: During today's visit, LPA interviewed two clients and two staff. No concerns noted.

No deficiencies observed. Exit interview conducted and a copy of the report issued.