Facility Evaluation Report

Licensing Program Analysts (LPA)'s Shawna Doucette and Sarah Hurt arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's were granted entry by Administrator. LPA's met with Administrator Nancy Cudal.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available.

Kitchen toured, appeared clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Resident rooms checked. LPA observed an adequate supply of linen. Hot water measured in a sample of rooms on both halls measuring at 106.2 F 110.4 degrees F. Facility was set at 82 F in main area. Each individual room had its own air conditioner keeping the rooms cool.

Exterior tour conducted, all exits open and free of obstructions. LPA's observed windows to have screwed in plastic covers covering the windows. LPA's observed damaged screens in the courtyard. Gate was observed to be self-latching.

Fire extinguisher serviced on 05/20/2025. Smoke detectors and carbon monoxide detectors observed operational. Facility has a sprinkler system that is serviced annually. Last fire drill conducted 04/10/2025. All cleaning supplies are locked and secured in a storage closet. Medications were locked in a medication cart in a locked medication room. .

LPA reviewed staff and client files. Centrally stored log was complete.