Facility Evaluation Report

On 11/13/2025, Licensing Program Analyst (LPA) J. Duarte conducted an unannounced

annual required inspection visit. LPA met with Direct Support Professional Ashley Williams and Administrator Sharon Johns. The administrator stated that there are currently six residents; however, all residents were at day program.

LPA inspected the interior and the exterior of the facility with the administrator. The facility was observed to be well lit, odor free, and at a temperature of 74 degrees F. The facility living room and dining room were observed to have adequate seating available. Resident bedrooms toured, bedrooms observed to have all required furnishings. Resident bathrooms toured, water temperature in restrooms measured between 108.4 and 109.3 degrees F. LPA observed kitchen to have sharps locked in a drawer. Facility observed to have a seven day supply of perishable and a two week supply of nonperishable food. Medication was also locked in a cabinet. LPA reviewed a sample of medications and MARS. Medications were observed to be administered as prescribed.

The outside of the facility was toured and no hazards were observed. Facility has seating available for residents at the front of the house, side of the house, and in the back patio.

Fire extinguishers present, one located in the hallway and one in the kitchen, which were serviced on 05/05/2025 and on 05/28/2025. Smoke and Carbon Monoxide detectors present and observed operational. Last Fire drill conducted 10/01/2025, according to facility records.

LPA reviewed a sample of resident and staff files and were observed to have required documents.