Facility Evaluation Report

Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct an annual required inspection. LPA met with Administrator Adaminah Victoria and explained the purpose of the visit. LPA verified all staff present received their criminal record clearances and were associated to the facility.

This is a short-term residential Social Rehabilitation Facility. LPA toured facility inside and out. LPA observed a quiet room, library, and kitchen/dining room for the residents' use. LPA toured the kitchen and observed a sufficient two (2) day supply of perishable and seven (7) day supply of non-perishable foods. LPA observed disinfectants and cleaning supplies were kept locked. LPA observed that all outside passageways and exits were free of obstructions. LPA observed auditory signals leading to outside areas were in working order. LPA observed that all centrally stored medications were locked and centrally stored medications were properly labeled and physician orders were maintained in the file. LPA observed that a comfortable temperature was maintained throughout the facility. LPA observed first aid kits were maintained and that the fire extinguishers were last serviced on 10/01/2024. Water temperature measured at 106.1. A sampling of staff and resident files were reviewed. Facility staff have sufficient training to meet resident needs and are First Aid and CPR certified. Residents have updated needs and services plans.

LPA observed the facility is in substantial compliance. No deficiencies are being cited during this inspection. Exit interview conducted and a copy of this report provided.