Facility Evaluation Report

Licensing Program Analyst Shawna Doucette (LPA) arrived at the facility unannounced to conduct a Required Annual inspection. LPA was granted entry into the facility by Staff Destiny Enriquez-Hernandez. Staff contacted Administrator who responded to assist with the visit. LPA met with Administrator Ashley Voight.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature set at 72 F. Common areas were furnished well with adequate seating and lighting available. Kitchen was clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Resident rooms were checked and were clean. Medications were locked in a closet. LPA observed an adequate supply of linen. Hot water measured at 116.4 degrees F.

Fire extinguisher serviced on 8/1/2025. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has a pull station fire alarm with sprinkler system. Last fire drill conducted 09/1/2025. All cleaning supplies are locked and secured in a cabinet under the kitchen sink.

LPA reviewed resident and staff records. Medications were checked. LPA observed emergency food supply located in the garage.

Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching. There was outdoor seating for clients.

An exit interview was conducted with the Administrator and a copy of this report was provided.