Observations
Based on an inspection of the physical plant, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
A fire extinguisher was found in the hallway of the facility that was labeled as being inspected in January of 2025. The fire extinguisher was due to be re-inspected no later than January of 2026. However, no further inspections were documented for the fire extinguisher.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"On 5/26/2026 landlord provided fire extinguisher with an up to date inspection. Approved & viewed by Facility Director.
Starting 6/12/2026 Clinical Director will arrange yearly inspections on all fire extinguishers in all office locations by a local extinguisher company and secure documentation for inspections. This location will require coordination with landlord & clinical director initiating contact every January.
Facility Director will review Inspection log yearly in January." |
Observations
Based on a review of fire drill records, the facility failed to conduct fire drills on different days of the week.
Fire drill logs were reviewed from June 2025 through May 2026. Fire drills took place on the following dates: June 9, 2025, July 7, 2025, August 4, 2025, September 1, 2025, October 6, 2025, November 3, 2025, December 1, 2025, January 5, 2026, February 2, 2026, March 2, 2026, April 6, 2026, and May 4, 2026. All fire drills were conducted on a Monday.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"Administrative assistant & counselor in each office were trained to conduct fire drills on 6/12/2026. Administrative assistant & counselor will complete documentation reflecting random dates & shifts of fire drills conducted.
Clinical Supervisor will review documentation of random fire drills on the last day of each month.
All Fire Drill logs will be reviewed each quarter by Facility Director." |