Facility Evaluation Report

On 12/11/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Pre-Licensing Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. Administrator, Precious Brown, is not available. Facility staff contacted Assistant Administrator, Triege Surratt via telephone. Assistant Administrator was unable to attend this inspection, LPA received verbal permission to meet with facility staff, Bola Anthony. There is one client present during today's inspection.

This is a 7 bedroom, 2 bathroom home. This facility is being licensed as a change in ownership. A fire clearance was granted for 6 Ambulatory clients.

LPA reviewed facility records and observed the following: The infection control plan and emergency disaster plan were provided and reviewed. LPA reviewed client records for admission agreements, medical assessments, and care plans. LPA was unable to review staff files during today's inspection. LPA found that S1 is fingerprint cleared, but was not associated to the facility. LPA observed client roster to not be updated.

LPA conducted a facility tour with staff. LPA observed that furnishings in the common areas (living room and dining room) were in need of repair/cleaning and/or replacement. Resident bedrooms were observed to be clean and had required furnishings. LPA observed the bed frame for R3 to have a large hole in the headboard and is in need of replacement. The lamp in R2's bedroom is missing a lamp shade. Bathrooms were observed to be clean and operational. Hot water measured at 113.3 degrees F. LPA did not observe required postings including the facility visitation policy. A sample menu was observed. LPA observed the facility food supply. Medications were observed to be locked and inaccessible during today's inspection. First-Aid kit observed. Fire Extinguisher was last serviced on 12/20/2023. Smoke detector and carbon monoxide detector observed to be operational during today's inspection.