Facility Evaluation Report

On 7/20/23 at 1:55 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Tracy Mitchell and explained the purpose of the visit. The facility’s fire clearance was approved for 8 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms on the main level which 2 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70-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 106.2-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.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 6/09/23. First aid kit was observed to be complete. Fire drill was last conducted on 6/12/23.

At 2:05 p.m., 3 of 3 clients’ records were reviewed. At 2:30 p.m., 2 staff records were reviewed, and 2 of 2 have current first aid training and associated to the facility. A sample of 3 client’s medications were reviewed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/27/23 LIC 610E Emergency Disaster Plan

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