Facility Evaluation Report

Licensing Program Analysts (LPA) Ana conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) on 12/29/2021 for a change of ownership license for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18-59 years. The requested capacity is for (3) clients, 3 ambulatory and 0 non-ambulatory. Structure: Facility is a three (3) bedroom, one (2) full bathroom, single story house with front yard, detached 2 car garage in the rear of the property. The facility is a red brick structure with rear patio and backyard. Front yard landscape is in good condition. Rear patio is covered with shaded umbrella. Back patio has table, chairs, and washer/dryer area has a utility sink. Signal System : No signal system in facility.

Bedroom Residents: There shall be no more than two clients per bedrooms. bedrooms are designated client private bedrooms properly equipped with regulation guidelines of 1 bed, 1 chair, 1 night stand, and overhead lighting. Presently, 3 bedrooms are occupied by 3 client. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: 2 full bathroom located in between the 3 bedrooms of east side of the facility. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in each of the 3 clients bedrooms. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in dining room bulletin board. Facility has a land line telephone located in the kitchen area. 2 Fire extinguisher, one 1A10BC mounted in kitchen wall, and the second 4A60BC in the hallway where bedrooms are located, which are labeled, they are tagged with current annual checks.