Facility Evaluation Report

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a required annual inspection and met with Administrator Alan Coulter. This facility is at the same address as a locked Mental Health Resource Center. LPA toured the building and grounds and found all areas of the facility to be kept clean and in good repair. LPA observed all exits and walkways were unobstructed. There are multiple client rooms, and all areas contained required furniture and appliances were found in good working order. Toxins and cleaners are stored in a locked facility janitorial room and in locked cabinets in the laundry room. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. LPA toured the main kitchen in which meals for all campus programs are provided. The pantry was heavily stocked with fresh and nonperishable foods, as well as emergency supplies. LPA observed back up linens and personal hygiene supplies for clients on hand. The facility has a vehicle for transportation which is serviced monthly. LPA observed medications are stored in a locked medication room. Medications were locked and inaccessible. Centrally stored medication records, along with progress notes and care plans are kept on a computer database with all client information. LPA reviewed 6 of 14 client files and found all clients have current assessments indicating all client's needs and services and current physician's reports. Staff were found to have current first aid and CPR certification. Staff have the required annual training documented in their files. Emergency drills are performed monthly and cover various types of emergencies. The last documented drill was conducted on 10/29/2024. Client finances are documented by the business office and client money is secure.

No deficiencies were found in the areas inspected, No citations issued.