Facility Evaluation Report

On 03/13/2026 at 11:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Clinical Director, Louise McClellan, and explained the purpose of the visit. There are currently 37 participants with a max capacity of 108 participants.

LPA toured facility including but not limited to bathrooms, kitchen, and common areas such as a computer room and art room. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 70.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 113.5 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/02/2025.

At 12:30PM, LPA reviewed five (5) participant files and six (6) staff files, all found to be complete. The emergency disaster plan was last reviewed 09/23/2025. Quarterly emergency drills were last conducted 02/06/2026.

No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the Clinical Director.