Observations
Based on the physical plant inspection the recovery house failed to maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Deficiency:
The facility failed to maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor containing resident bedrooms. During inspection, one designated emergency exit window was found obstructed by an air conditioning unit.
1. Corrective Action Taken:
The obstructing air conditioning unit was immediately removed from the designated emergency exit window on July 24th, 2025. This action restored the second means of egress on the affected floor.
2. Plan to Ensure Ongoing Compliance:
- The House Manager (Joseph Beck) conducted a walkthrough of all floors to verify that all designated emergency exits are unobstructed and meet separation requirements.
- Signage was posted on all emergency exit windows stating: "Do Not Block ? Emergency Exit."
- The House Manager reviewed emergency egress protocols with all residents and staff
- All staff were reminded that no items (including A/C units, furniture, or decorations) may obstruct emergency exits at any time.
- Going forward, the House Manager will inspect all exit areas as part of routine facility checks.
3. Prevention of Recurrence:
To ensure this issue does not recur:
- All new and current staff will be trained on emergency exit requirements during onboarding and ongoing monthly safety trainings.
- Any violations will be addressed immediately with corrective action and retraining.
4. Responsible Parties:
- House Manager (Joseph Beck): Responsible for implementation, ongoing monitoring, and facility checks
- All staff: Responsible for maintaining awareness and reporting potential obstructions
5. Timeline for Full Compliance:
The facility was in full compliance as of 7/24/2025. Ongoing monitoring and staff training are already in effect and will continue
6. Authorized Provider Name:
Antonio Kadylak
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