Facility Evaluation Report

On February 27, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced to conduct a Required Annual Inspection. LPA met with Associate Director, Shelley Stephens, and On-site Administrator, Sarah Silva, and explained the purpose of the visit. At the time of the inspection, 18 clients and 7 staff were present in the facility. 20 additional clients and 6 staff were on a field trip to the Jelly Belly Factory. LPA observed clients participating in yoga class, playing games, and doing crafts.

The main facility (pavilion) is currently under construction and is unable to be used by clients due to mold being discovered during a renovation. The facility is temporarily utilizing four front office spaces as classrooms and clients are taking more outings into the community while the main pavilion is being completed.

LPA Adkison and Administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to: four activity rooms/classrooms, storage areas, kitchen, a common room, and two (2) bathrooms. All clients bring their lunch from home, however, the facility was providing a pizza party for clients during the inspection. The facility has a plethora of activities for client use including, games, puzzles, and art supplies. There is a calendar of activities, events, and classes, posted for clients to observe and sign up for each day.

All areas observed were found to be clean and in good repair. LPA observed all walkways to be free of clutter or obstructions. All clients bring their lunches from home. There are additional snacks available for clients. LPA observed all, cleaning supplies, medications, and other toxins to be locked away and inaccessible to clients in care. LPA reviewed the Medication Administration Record (MAR) for one (1) client and found it to be in compliance.

The facility was observed to be at a comfortable temperature. Fire extinguishers were fully charged and last inspected in September 2025. Carbon monoxide detectors were observed and were in working order. The facility's temporary space did not have a smoke detector. A maintenance worker obtained a smoke detector during the visit and had it installed while LPA was in the facility. The last disaster drill was conducted and documented in January 2026. The facility is conducting drills monthly.

LPA reviewed five (5) staff files and five (5) client files which contained all the required documentation. All employees requiring background checks are cleared. All CPR/First Aid training was current.

No deficiencies are being cited as a result of this inspection. Exit Interview conducted. A copy of this report and Appeal Right were provided to Shelley Stephens, Associate Director, via email