Facility Evaluation Report

On 07/21/2026 at 09:30 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met Operations Director, Willetta Frizzle and explained the purpose of the visit. At 9:45 AM, LPA called Executive Director, Laura Weissberger and explained the purpose of the visit. Executive Director was not present during inspection.

At approximately 9:50 AM, LPA toured the facility including but not limited to 6 bedrooms, 4 bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 68 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 109 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of one-week supply of non-perishables and 2-day perishables food supply. Sharps and knives were observed to be locked in a locked container.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was scheduled to be serviced on 07/22/2026. LPA reviewed facility's Emergency Disaster Plan. Emergency Disaster Plan was last posted on 07/21/2026. First aid kit was observed to be complete. Fire drill was last conducted on 07/04/2026.

At 10:55 AM, LPA observed Social Rehabilitation Approval Certificate issued by HCS posted and prominently displayed on the wall.

At 11:05 AM LPA checked a sample of 5 resident's medications. Medications were stored in a locked storage.

At 12:10 AM LPA reviewed Staff Roster, 5 resident records and 5 resident records, and all were complete.

No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.