Facility Evaluation Report

On 02/28/2025 at 9:10am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Jacquelin Medina, DSP and the purpose of today’s visit was explained. The facility is licensed for (4) ambulatory adults ages 18-59 years of ages. Currently, the home has (4) clients. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facility annual fees $0 (payment of $454.00 made on 01/29/2025 at 4:07pm). The last fire drill was conducted 02/12/2025 at 5pm. The liability insurance is with American Southern Home Ins. Fund with effective date 02/21/2025 - policy expiration 02/21/2026 and the policy # G8A6GL000005302.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: three (3) clients' rooms, two (2) common bathrooms, (2) staff rooms, a living area, a dining area, a kitchen,a den,a backyard with 2 locked sheds and a covered jacuzzi, a garage with a washer, a dryer and two additional refrigerators and an outside patio area (in the front of the home and in the backyard).

Between the hours 9:30 am - 10:30am of LPA conducted a records review of (4) client records, (4) staff records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records and did not observed any discrepancies at the time of visit.