Facility Evaluation Report

On 6/08/23 at 12:40 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Joe Douglass and explained the purpose of the visit. The facility’s fire clearance was approved for 32 clients of which 26 may be non-ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 18 total bedrooms which all are occupied by the clients. 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 kitchen was measured at 116.5 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene were 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 10/14/22. First aid kit was observed to be complete. Fire drill was last conducted on 4/27/23 .

At 1:30 pm, 5 clients records were reviewed. At 2:15 pm, 5 staff records were reviewed and 5 of 5 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 6/15/23: LIC 610E Emergency Disaster Plan

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