Facility Evaluation Report

On 04/16/2025 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Direct Care Staff, Shanita Richmond. LPA introduced self, explained reason for visit and was permitted entry into the facility. Licensee arrive some time later. Residents arrived some time later from day program.

LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 10/23/2024. Last fire drill on 2/15/25. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closet. Sharps, chemicals and medications in locked cabinets.

The following issues were observed during todays visit: Hole behind door on bedroom #1 and in laundry room in need of repair. Carpet in doorway of bedroom #1 observed frayed and in need of repair. Door in bedroom #2 dirty and in need of cleaning/touch-up paint. Bathroom in bedroom #3 in need of touch-up paint. Recliner chair in bedroom #3 observed with a tear in need of repair. Doorway trims throughout the facility in need of repair/touch-up paint. Debris on right side yard in need of removal. Gate on left side of yard does not open/close properly in need of repair. Small chest freezer in need of defrosting. Large chest freezer not working in need of removal. Refrigerator/freezer in garage in need of cleaning/defrosting. Kitchen wall in need of repair/touch-up paint.