Facility Evaluation Report

On September 10, 2025, Licensing Program Analyst (LPA) Kayla Adkison and Regional Manager (RM) Alycia Rayner, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Stephanie Allan, and Esther Parris, Direct Service Provider (DSP) , and explained the purpose of the visit. One (1) resident and three (3) staff were present in the facility during the inspection.

LPA, RM, and DSP toured the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, kitchen, garage, backyard, and two (2) common restrooms. All areas observed were found to be clean in good repair.

LPA observed each bedroom to have the required furnishings, working lights, and windows with screens. Facility has a 2-day perishable and a 7-day non-perishable amount of food. The facility has a menu posted for clients. LPA observed all sharps to be kept locked in a kitchen drawer and inaccessible to residents. Hot water temperature measured within Title 22 regulations of 105 F and 120 F. LPA observed medications to be locked in the med room and inaccessible to residents in care. LPA observed Medication Administration Records (MAR) and found them to be in compliance. LPA observed a calendar of events for clients to view. The facility has variety of games, cards, and activities available for client use.

LPA observed two (2) fire extinguishers which were last inspected in September 2024. LPA observed an emergency disaster drill log with the last drill conducted in September 2025. The facility is conducting drills monthly. LPA observed a complete first aid kit ready for emergency use.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of four (4) residents' files and five (5) staff files. One staff file was missing a record of a negative tuberculosis examination.

Deficiencies are being cited as a result of this inspection (See attached LIC 809-D). Exit interview conducted. A copy of this report and Appeal Rights were provided, via email, to Administrator, Stephanie Allen.