Facility Evaluation Report

On this day at around 10:10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and was met by staff Geneva Renfro. LPA explained to Geneva the purpose of visit. Administrator Natalie Johnson arrived at around 1:10 pm.

Facility is a two storey structure with 1 shared client room on the lower level and 3 other rooms on the second level, one of which is the staff room and the 2 shared client rooms. One staff room is located next to the dining area. Facility was observed to be clean and odor free. There were sufficient lighting and furniture.

Hot water measured at 111 degrees Fahrenheit in the bathroom and kitchen. There was sufficient supply of perishable and non perishable foods. Chemicals were observed locked in the laundry room. Medications and sharp objects/knives were locked separately. Hallways and passageways were free of obstruction. Fire extinguisher appeared full and was last serviced on 1215/2022 . Facility has a dual carbon monoxide and smoke detector that were tested and observed operational. Bath/shower rooms were observed with grab bars, non skid mats and hygiene products. Ample supply of linen, towels and warm blankets were observed. First aid kit was complete.

No client was present during inspection. Administrator states all clients are at their respective day programs.

At around 11 am, LPA reviewed 2 client and 2 staff files. At around 12:15 pm, LPA reviewed Medication Administration Record (MAR) and medication for 2 clients. At 2:10 pm, LPA interviewed 2 staff. LPA attempted to interview 2 clients. Last fire drill was conducted on January 2023.

At around 10:25 am, LPA observed steak knife unlocked in one of the drawers in the kitchen. LPA asked staff to lock knife during inspection.