Facility Evaluation Report

On 11/04/2024 at approximately 8:30 a.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at this facility. LPA was greeted by staff #1(S1), William Tan , who granted access to the facility. S1 contacted the Administrator, Clifton VonBuck, LPA explained the reason for the visit. Clifton designated S1 to sign todays report. Administrator met LPA at the facility at 10:30 a.m.

At approximately, 8:48 a.m. LPA conducted a physical plant tour of the facility and the following was observed:

The facility is licensed for an Adult Residential Facility, and has an approved fire clearance for a capacity of 6 ambulatory clients.

Common Areas: LPA observed living room and dining room clean and clear of clutter. William was observed sweeping the floors. Furniture is in good repair. LPA observed a fireplace in the living room secured with a screen. Dining table and chairs sit the capacity of the facility.

Laundry / Garage: Laundry room is kept locked. Chemicals and detergents are kept locked in laundry room. LPA observed washer and dryer in use and operational. Client files are kept locked in the laundry room. Laundry room leads to garage. Garage is used to store facility supplies and is maintained locked.

Kitchen: LPA toured the kitchen area and observed seven day non-perishable supply of food and a two day perishable supply of food; properly stored. Cleaning products, knives and sharps were observed locked in a kitchen cabinet under the sink. A Fire extinguisher was observed by the kitchen to be fully charged with last serviced date 03/18/24. (Continued on LIC809-C)