Observations
Based on the review of the facility's fire drill log for the months of December 2022 through October 2023, the facility failed to prepare alternate exit routes to be used during fire drills.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 12, 2022 annual licensing inspection.
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Plan of Correction
The Executive Director, Lead Counselor, Counselor and attending clients will use the main entrances as well as the identified alternative exits during fire drills. The exit used will be documented on the monthly fire drill report.
The Executive Director will be responsible for monitoring the fire drills to assure that each exit is used randomly on an ongoing basis. |