Facility Evaluation Report

On 08/04/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and met with Administrator Rosalind Ward. Two clients arrived later during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Fire extinguisher was observed with a service date of: 02/21/26. Fire drill last completed on 6/30/26.

An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -2 degrees F and refrigerator temperature was maintained at 38 degrees F. Clients' bedrooms were toured and observed to be adequately furnished and with adequate lighting. Bedroom #2 observed for bedridden. All bathrooms were toured and observed to be operational. Hot water temperature was tested 105 degrees F. in bathroom 1 and range between 109.2 and 108.1 degrees F. in bathroom 2 and 105.4 degrees F in bathroom 3. Medications were checked and observed kept locked in hallway shelf. Cleaning chemicals were observed stored and locked in the garage cabinet. Outside of facility toured.

Side gates were self-closing and self-latching. Outside was observed with adequate outdoor seating available for clients and free of debris. All clients’ files reviewed to have required records. LPA reviewed a sample of staff files to have current First Aid/CPR, good health screening, fingerprinted cleared, and associated with facility. Carbon monoxide and smoke detectors were tested and observed to be operational. Fire sprinkler observed throughout the facility.

A deficiency is being cited on the attached Lic 809D. Exit Interview conducted. The requested documents are to be submitted to the department by 08/10/26: Lic 308, Lic 500, Lic 610D, Lic 9020, and current Administrator certificate. A copy of this report and appeal rights were provided to Administrator, whose signature on this form confirms receipt of this report.