Facility Evaluation Report

Licensing Program Analyst LPA Shawna Doucette arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by Staff Alyssa Sarmiento and explained the purpose of the visit. LPA contacted Administrator Lareese Delouth who responded to assist with the visit.

A tour of the facility was conducted with the Administrator. The residence was set at 68 and 73 F temperature and free of passageway obstructions inside and outside.

LPA observed four bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean. Hot water temperature was measured 105.2 F.

Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. Knives were stored in a locked drawer. Medications were stored in a locked medication cart. Cleaning supplies were in a locked cabinet in laundry room. Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguishers were charged and had service dates of 1/21/25. Fire drill was last completed on 09/29/25. Facility has a pull station fire alarm. Facility has a sprinkler system. There was outdoor seating for clients. Pool is fenced and inaccessible to clients. Pool gate lock was locked.

Resident, medication and staff records were reviewed. C1 did not have an admissions agreement. C1 and C2 do not have centrally stored logs. Current first aid and CPR were on file for staff.

An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeals rights were discussed and left with the Administrator.