Facility Evaluation Report

On 12/09/2025 at approximately 1:05 p.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 asked LPA to sign in. LPA observed required postings along a wall near the common areas. S1 contacted the Administrator, Clifton VonBuck, LPA explained the reason for the visit. Clifton designated S1 to sign todays report. The facility is licensed for an Adult Residential Facility, and has an approved fire clearance for a capacity of four (4) ambulatory clients.

At approximately, 1:07 p.m. LPA initiated a physical plant tour of the inside and outside of the facility and the following was observed:

Common Areas: LPA observed living room and dining room clean and clear of clutter. LPA observed Staff #2 (S2) in the facility wrapping gifts. LPA observed the facility’s furniture is in good repair. The dining table and chairs accommodate the capacity of the facility. A facility telephone was observed on the peninsula counter and is accessible to clients. LPA did not observe tripping hazards.

Kitchen: LPA toured the kitchen area and observed a seven day non-perishable supply of food and a two day perishable supply of food. 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 03/12/25.

Laundry / Garage: The laundry room is kept locked. Chemicals and detergents are kept locked in laundry room. 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. (Continued on LIC809-C)