Facility Evaluation Report

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a Required Annual Inspection. LPA explained the purpose of the visit. LPA was granted entry by Staff Xinia Ulloa. LPA met with Program Director Christina Pittman.

A tour of the facility was conducted with Program Director. The facility was set at 72 F temperature and free of passageway obstructions inside and outside. Water measured at 113.3 F.

LPA observed several activity rooms where clients were participating in activities.

Kitchen was toured. Cleaning supplies were locked in two separate storage rooms. Smoke detectors are hard wired through an alarm company. Facility is wired with sprinkler system. Fire extinguishers were charged and had service dates of 7/28/25. Emergency drills are conducted monthly.

Client and staff records were reviewed. Facility files were not readily available to review. LPA reviewed Inection Control plan in previous annual but it was unable to be located during the current inspection. 2 out of 4 client records review did not have LIC 602. Current first aid and CPR were on file for staff.

An exit interview was conducted with the Program Manager and a copy of this report was provided with plans of correction and appeal rights.