Facility Evaluation Report

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by House Manager Gail Earnest Sanders. House Manager contacted Administrator Lereese Delouth who responded to assist with the visit.

LPA toured the facility. The residence was set at 73 F temperature and free of passageway obstructions inside and outside. LPA observed 4 bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean. Hot water temperature was measured 105 F.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication cart. Cleaning supplies were in a locked cabinet in the garage. 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 02/27/25. Facility has a pull station fire alarm. Facility has a sprinkler system.

Resident, medication and staff records were reviewed. Facility had a medication error 5/22/25. C1's medication was administered to C2. Facility does not have centrally stored log. Current first aid and CPR were on file for staff.

Facility does not have disaster plan filled out on pages 5 through 9.

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