Facility Evaluation Report

Licensing Program Analyst (LPA) Glenn Trueman made a visit to the facility and was greeted by Staff Adina Agent and explained the reason for the visit.

The purpose of the visit is to conduct the required 2024 annual inspection.

Annual Inspection includes the following Domains:

Infection Control, Physical Plant and Environmental Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client rights- Incident Reports, Food Service, Health Related services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention.

Tour of the facility was conducted and the following was observed:

There are 3 Client Bedrooms which have the required furniture such as bedframes, dressers, lamps and chairs.

Beds have the required linen and the linen is in good condition.

There is 1 Client bathroom. The bathrooms are clean and have the required hygiene items. The hot water temperature was within the required 105 - 120 degrees.

The facility temperature at the time of the visit was comfortable.

There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility. There is a carbon monoxide detector. The kitchen was inspected. There is sufficient perishable and non-perishable food. The food was also stored properly. Kitchen appliances are clean and are operating properly. The front and backyard are well maintained. There is no pool or other large bodies of water.

2 Staff were interviewed. Clients were all out in the community at Day Program.

Staff Files were not able to be accessed. The key to open up the locked cabinet to access the staff files was not at the facility.

Technical Advisory for First Aid unable to be reviewed in staff files.

Exit interview conducted and copy provided.