Facility Evaluation Report

On 06/06/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator Eve Tighe and explained the purpose of today’s visit. The facility is licensed to operate for six (6) developmentally disabled adults between the ages of 18 through 59.

The facility is single story structure located in a residential neighborhood. It consists of the following: three (3) client rooms, two (2) client bathrooms, one staff room used for office space as well, one (1) living area, one (1) dining area, kitchen, and outside patio area with a table and umbrella for shade.

LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 105.0 F to 106.7 F in the bathrooms and kitchen sink. The laundry area is located next to the kitchen. A comfortable temperature of 74 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies and toxins were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The grocery shopping takes place every three to four days. There are two (2) fire extinguishers fully charge, one (1) in the kitchen and one (1) at the end of the hallway, smoke detectors and carbon monoxide were operable. A reviewed of Medication Records Administration (MAR) and observed to be maintained in order and accurate.