Facility Evaluation Report

Licensing Program Analyst (LPA) Glenn Trueman conducted the required annual inspection on 01/16/25. LPA arrived unannounced and met with Administrator Shannon Steib The reason for the visit was explained. The facility is licensed as a social rehabilitation facility to serve mentally disabled adults with a capacity of 13 and ambulatory only. There are currently 11 clients residing at the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the facility.

Infection Control: Staff are continuing to clean and disinfect each day. They are using appropriate hand hygiene and wearing gloves when necessary to assist clients. The facility has submitted the Infection Control Plan.

Physical Plant & Environment Safety: The facility consists of individual units: Unit #9 consists of 2 client bedrooms, 1 bathroom, and common areas; Unit #3 consists of 2 client bedrooms, 1 bathroom, common areas, and a staff office next door; Unit #8 consists of 2 client bedrooms, 1 bathroom, living room, and kitchen; Unit #4 is an individual client room with a private bathroom; Unit #5 is a library; Unit #6 is utilized as the staffing offices; and the Wellness room is utilized for individual sessions. There are smoke and carbon monoxide combo detectors located in each unit. Cleaning solutions and disinfectants are locked and inaccessible to clients.

Operational Requirements: The facility is adhering to operational requirements. Staff are providing care and supervision to meet the needs of the clients.

Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin.

Staffing : There is sufficient staffing at the facility. There are no clients who rely on staff to perform all activities of daily living. Interviews were conducted with 3 Staff.

Personnel Records-Training : The Social Rehabilitation facility has an administrator. Staff files are maintained at the facility. Staff receive on-going training throughout the year and have current first aid training. LPA reviewed (5) personnel files and all have required documentation in their files.