Facility Evaluation Report

On 10/27/2025 around 8:00AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct a Required 1-year inspection. LPA met with administrator Sister Mary Ann Lebya and explained the purpose of the visit. The facility currently houses two (2) residents of the max capacity of three (3).

LPA and ADM toured the facility including but not limited to bedrooms, bathrooms, kitchen, common areas front yard backyard. All passageways were free of obstruction; no bodies of water were present. There was a comfortable temperature for clients at 70.0 degrees Fahrenheit. LPA observed adequate lighting and furniture in all rooms for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom measured at 112.2 degrees Fahrenheit.. The shared bathrooms had soap, hand towels and garbage cans. There was a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. Smoke detectors/carbon monoxide unit were in operating condition during visit. Fire extinguisher was last serviced on 01/06/2025.

At 9:30AM, LPA reviewed both resident files and three (3) staff files, all found to be complete. Emergency Disaster Plan last reviewed 07/24/2025. Quarterly emergency drills were last conducted 09/27/2025.

No deficiencies cited. Exit interview conducted. A copy of this report provided to administrator.