Inspection Reports for
Friends of Switchpoint, Inc DBA Switchpoint Canyon Rim
1871 East 3300 South, Salt Lake City, UT, 84106
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
39 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
394% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
85% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 35
Capacity: 41
Deficiencies: 41
Date: Mar 14, 2025
Visit Reason
The inspection was an announced annual licensing inspection to assess compliance with licensing rules and regulations for the Friends Of Switchpoint - Canyon Rim facility.
Findings
The inspection identified multiple noncompliance issues across various regulatory areas including licensing procedures, incident reporting, program policies, medication management, physical facility safety, client record requirements, clinical services, staffing, personnel training, and specialized services. The provider has plans to correct some deficiencies by April 15, 2025.
Deficiencies (41)
R380-600-3(1) The provider accepted fees and provided client services without an approved license or certificate.
R380-600-3(3) The provider did not permit immediate, unrestricted access to licensing staff for sites, client records, staff, and clients.
R380-600-3(14) The provider failed to adhere to individualized parameters on the program license to promote client health, safety, and welfare.
R380-600-3(24) The provider did not post the current license or certificate in a publicly accessible place on the premises.
R501-14-5(2)(a)(b) The provider failed to submit initial background screening applications timely and did not document supervision of applicants until clearance.
R380-600-6(5) The provider did not sign or comply with approved variances as required.
R380-600-7(6) The provider compromised the integrity of the office's information gathering by withholding or manipulating information.
R380-600-7(16) The provider failed to submit critical incident reports to the office within one business day and notify legal guardians timely.
R501-1-4(2) The licensee did not develop, implement, and comply with safe practices ensuring client health and safety and staff awareness.
R501-1-4(3) The licensee failed to submit changes to office-approved policies or curriculum for approval before implementation.
R501-1-5(1) The licensee did not ensure compliance with medication management safe practices including staff training and error reporting.
R501-1-5(2) The licensee failed to ensure care, vaccination, licensure, and maintenance of animals on-site including allergy assessments and supervision.
R501-1-5(4) The licensee did not ensure a one-to-one staff to client ratio during transports based on safety assessments.
R501-1-6(1) The licensee failed to clearly identify services, complaint processes, eligibility criteria, fees, and supplemental services to clients and the public.
R501-1-8(1)(c) The licensee did not document fire drills as required, though a plan to document future drills was in place.
R501-1-8(1)(a)(b)(d)(e)(f)(g)(h)(i) The licensee failed to maintain building cleanliness, safe appliances, emergency phone access, bathroom privacy and supplies, and proper medication storage.
R501-1-8(2) The licensee did not accommodate clients with physical disabilities as needed.
R501-1-8(3) The licensee failed to maintain medication and hazardous items securely and responsibly.
R501-1-8(4) The licensee did not maintain a first aid kit as required.
R501-1-9(1)(a)(c)(e)(f)(h)(i)(k)(l)(m)(p) The licensee failed to provide adequate designated spaces, privacy, hygiene supplies, natural light, and proper bedroom conditions.
R501-1-9(2) The licensee housed more than two clients in a bedroom serving individuals with disabilities.
R501-1-9(3) The licensee did not comply with seclusion room standards including size, ventilation, observation, and use restrictions.
R501-1-9(5) The licensee failed to ensure alternate sleeping arrangements were individualized, short-term, and clinically justified.
R501-1-10(2)(a)(b)(c)(d)(e)(f) The licensee failed to ensure meals were not used as incentives or punishment and did not provide nutritional counseling or safe food handling.
R501-1-10(3) The licensee did not ensure self-serve kitchen users were supervised and trained by qualified staff.
R501-1-10(4) The licensee did not maintain written consent for consenting adult clients managing special dietary needs.
R501-1-10(5) The licensee failed to document staff training on identifying and accommodating clients with special dietary needs.
R501-1-10(6) The licensee did not inform staff and clients in writing about kitchen use rules, menu planning, and food safety when meals are client-prepared.
R501-1-11(1) The licensee failed to maintain complete client records including intake, assessments, treatment plans, progress notes, consents, and incident reports.
R501-1-12(1)(2)(3)(4)(5) The licensee did not complete required intake screenings, suicide risk assessments, criminogenic risk assessments, or maintain signed client agreements.
R501-1-13(1) The licensee failed to complete intake assessments within seven days including cultural, medical, and emergency care authorizations.
R501-1-14(1)(2)(4) The licensee did not provide clinical treatment services or ensure treatment plans and documentation as required.
R501-1-15(1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11) The licensee failed to ensure adequate staffing, background clearances, tuberculosis screening, medication oversight, personnel records, and CPR/First Aid certification.
R501-1-16(1)(2) The licensee did not provide required pre-service and annual staff training on program policies, emergency procedures, client rights, medication management, abuse prevention, and other required topics.
R501-22-3(3)(4)(5)(6) The licensee failed to provide evidence of coordination with local health authorities and did not identify key decision makers for homeless services.
R501-22-4(1)(2)(3) The licensee failed to provide 24-hour supervision, establish safe medical practices, and conduct background checks for volunteers.
R501-22-5(1)(2)(3)(4)(5)(6)(7)(8)(9)(11)(12) The licensee failed to meet bathroom and bedroom standards, provide clean linen, manage emergency overflow, and maintain safe practices for homeless and domestic violence shelters.
R501-22-6(1)(2)(3)(4) The licensee failed to screen clients and staff for tuberculosis and provide evidence of coordination with health authorities for substance use disorder programs.
R501-22-8(1)(2)(3)(4)(5)(6) The licensee failed to document shelter rules, supervise children, provide safety plans, and assist clients with referrals and resources in domestic violence shelters.
R501-22-10(1)(2)(3)(4)(5)(7)(8)(11)(12) The licensee failed to maintain required staffing ratios, emergency procedures, client agreements, and documentation for emergency homeless shelters and receiving centers.
R501-22-11(1)(2)(3) The licensee failed to complete and maintain residential attestation agreements and self-assessment surveys for clients with disabilities.
Report Facts
Number of Present Residents: 35
Approved Capacity: 41
Date to be corrected by: Apr 15, 2025
Inspection Report
Original Licensing
Census: 43
Capacity: 43
Deficiencies: 37
Date: Apr 9, 2024
Visit Reason
The inspection was conducted as a pre-license visit for Friends of Switchpoint, Inc DBA Switchpoint Canyon Rim to assess compliance with licensing requirements prior to program implementation.
Findings
The inspection identified one noncompliance related to program policies, procedures, and safe practices. Multiple areas including physical facilities, client record requirements, and specialized services were reviewed with several noncompliances noted, many of which were corrected during the inspection.
Deficiencies (37)
R501-1-4(1)(a-c) The licensee failed to submit policies and procedures before program implementation that include descriptions and procedures for preventing abuse, discrimination, and harassment, and professional communication with individuals of any sexual orientations and genders.
R501-1-4(2)(a-d) The licensee did not fully develop, implement, and comply with safe practices ensuring client health and safety, meeting client needs, avoiding conflicts with administrative rules, and informing staff about managing unique site circumstances.
R501-1-4(4) The licensee failed to submit policies and procedures describing behavior management, suicide prevention, restraint, or seclusion before implementation.
R501-1-4(5)(a-k) The licensee did not ensure behavior management techniques were trauma-informed, emphasized de-escalation, and complied with required standards including appropriate use of restraint and seclusion.
R501-1-6(2)(g) The licensee did not post the department code of conduct poster in a conspicuous place accessible to visitors, staff, and clients; this was corrected during inspection.
R501-1-8(1)(a-i) The licensee failed to maintain the physical facility and safety requirements including cleanliness, maintenance of appliances, fire drills, emergency phone availability, bathroom privacy and supplies, and proper medication storage.
R501-1-8(2) The licensee did not accommodate clients with physical disabilities as needed or refer appropriately.
R501-1-8(3) The licensee failed to maintain medication and hazardous items on-site lawfully and safely, including locked storage.
R501-1-8(4) The licensee did not maintain a first aid kit containing required items such as bandages, tweezers, antiseptic, and disposable sterile gloves.
R501-1-6(1)(g) The licensee failed to clearly identify services, including non-clinical and supplemental services offered or referred.
R501-1-11(2) The licensee did not document a plan detailing how program staff and client files are maintained and remain available for seven years.
R380-600-8(11) The licensee was found noncompliant with rules regarding license or certificate revocation actions.
R501-22-3(4) Residential support was found noncompliant for requiring treatment as a condition of admission.
R501-22-3(5) The licensee failed to provide evidence of ongoing coordination with local health authorities regarding communicable diseases.
R501-22-3(6) The licensee did not inform staff regarding communicable diseases, signs, symptoms, and outbreak procedures.
R501-22-4(2) The licensee failed to establish safe practices identifying medical attention needs and how the program meets client medical needs.
R501-22-4(3) The licensee did not conduct eligible background clearance and document required training for volunteers or students.
R501-22-5(1) The licensee did not ensure at least one bathroom for every ten clients as required.
R501-22-5(3) The licensee failed to comply with bathroom ratio requirements for emergency homeless shelters.
R501-22-5(4) The licensee did not develop safe practices to manage emergency overflow during dangerous weather conditions.
R501-22-5(5) The licensee failed to develop safe practices to allow and encourage clients to have clean linen at least weekly.
R501-22-5(6) The licensee did not have portable beds, cots, or mats to accommodate fluctuating client volume.
R501-22-5(7) The licensee failed to provide clean bedding laundered at least weekly or as needed.
R501-22-5(9) The licensee did not comply with bedroom standards for domestic violence shelters and family support centers.
R501-22-8(1) The licensee failed to document that shelter rules, reasons for termination, and confidentiality rights were provided verbally and in writing to each client.
R501-22-8(2) The licensee did not ensure parents supervised their own children or arranged appropriate child care.
R501-22-8(3) The licensee failed to ensure domestic violence shelter action plans included required reviews and referrals for victim safety and supportive services.
R501-22-8(4) The licensee did not assist with connecting clients to identified resources.
R501-22-8(5) The licensee failed to make and document referrals for victim treatment, psychiatric consultation, drug and alcohol treatment, or allied services.
R501-22-8(6) The licensee did not ensure shelter staff completing action plans were supervised by experienced and trained domestic violence providers.
R501-22-10(2) The licensee failed to ensure no less than two direct care staff were always present and maintain required staff-to-client ratios.
R501-22-10(4) The licensee did not comply with procedures for increasing capacity by 35% during code blue alerts.
R501-22-10(5) The licensee failed to require each adult resident to sign an agreement form outlining visitation and participation rights.
R501-22-10(7) The licensee did not maintain required client information or document reasons why information was not obtainable.
R501-22-10(8) The licensee failed to maintain documentation for re-opening client files for returns up to 30 days past last shelter stay.
R501-22-11(1-4) The licensee did not maintain required residential attestation agreement forms and self-assessment surveys for clients with disabilities.
R501-22-12(1-6) The licensee failed to outline safe practices, individualized clinical documentation, voluntary placement alternatives, and treatment mandates for receiving centers.
Report Facts
Number of Non Compliant Items: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hailey Feichko | Licensor | Conducted the inspection and explained noncompliance items |
| Cody Sanders | Individual informed of the inspection |
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