Facility Evaluation Report

On this day, March 6, 2025, at 10:45 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Program Director (PD) Ebonie Lemi, and informed the reason for visit.

LPA toured the facility inside out with PD. The facility is a two level building. LPA inspected the common areas, quiet room, library, media, computer and activity rooms, maintenance storage cabinet, parking area.

Clients are provided snacks and they bring their own lunch. Activity materials were observed sufficient for clients' use.

Facility has working carbon monoxide and smoke detectors. Fire extinguishers checked, observed fully charge, and tags showed serviced 1/16/25. Facility conducts disaster drills, and records showed last conducted 1/31/25. Water temperature in one of the toilets was tested and measured at 115.1 degrees Fahrenheit. Room temperature was at 72.6 degrees Fahrenheit.

LPA reviewed 5 staff and 5 clients files, and interviewed 2 clients. Facility does not handle clients' P&I and does not administer medications.

-at 11:05 am, client (C1) was out in the facility's open parking lot sunbathing without staff supervision. C1's LIC602A revealed C1 can not leave the facility unassisted and has wandering behavior.