Facility Evaluation Report

On 10/14/2025 at 8:30AM, Licensing Program Analysts (LPAs) Jim Sampair and Andrew Christy arrived unannounced to conduct the Required Annual Inspection of the facility. LPAs stated the purpose of the visit to Staff Member Kingsley Nwala. Program Manager Dara Stanton arrived at approximately 10:15AM.

The LPAs toured the interior and exterior of the 3 buildings on the facility grounds, including but not limited to client bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor areas. The LPAs observed adequate lighting in all of the rooms for the comfort and safety of the clients. LPAs observed 7 days of nonperishable and 2 days of perishable foods on hand. Sharps and dangerous items were inaccessible to clients. Client rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction. Smoke detectors and carbon monoxide detectors were fully functional. Fire extinguishers were observed to be full and last serviced on 05/21/2025. Temperature in the facility was measured at 70.0 degrees Fahrenheit at and the hot water in a resident's bathroom measured at 153.6 degrees Fahrenheit.

The LPA reviewed the records of 5 clients and 5 staff members, all found to be complete. The emergency disaster plan was last reviewed 05/29/2025. Quarterly emergency drills were last conducted 05/29/2025. A review of the residents' medications and Medication Administration Record (MAR) showed no outstanding errors.