Facility Evaluation Report

On 11/9/2023 at 12:45pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Annual 1-year required inspection. LPA met with Nikia Smith, Program Manager, and explained the reason for the visit. The facility's fire clearance was approved for 45 ambulatory and 30 non-ambulatory.

LPA inspected the facility with Program Director, which included but not limited to the bathrooms, kitchen, common areas, and the outside area of the facility. LPA observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. There is a comfortable room temperature of 73 degrees Fahrenheit for clients in care. Grab bars mats were observed in bathrooms and throughout the facility. Clients bring their own lunches and snacks to facility. The hot water temperature in the shared bathroom measured 113.5 degrees. All observed toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed. Carbon monoxide and smoke detectors found to be in working order. Centrally stored medications, toxins and sharp objects were locked and inaccessible to clients. Fire extinguisher last services 4/7/2023. Fire drill last conducted 5/26/2023. First aid kit was checked and is complete.

LPA reviewed five (5) staff files and all have current first aid & CPR certification. LPA reviewed six (6) clients and all were current and complete.