Facility Evaluation Report

At approximately 9:10 a.m. on 04/11/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit.

A file review was conducted prior to today’s visit.

The facility was last visited on 03/17/2024 for an annual inspection. It is a single story building with five (05) bedrooms, three (03) bathrooms, kitchen, laundry room, common areas, and outdoor areas. It has an approved fire clearance for five (05) ambulatory clients.

LPA observed a maintained front yard with multiple vehicles in the driveway. Postings at the front included COVID precautions, facility license, confidential complaints contacts, emergency disaster plan, personal rights, staff roster, client roster, house rules, and the facility sketch. A weekly menu and activity calendar were also posted in the facility.

Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained furniture in good repair and a television. A fireplace was appropriately grated. At 9:40 a.m. LPA measured the room temperature to be 75 degrees Fahrenheit. One (01) client was present in the home and was observed playing in the backyard with two (02) staff. Two (02) hallway closets contained hygiene supplies and fresh linens. A locked closet contained cleaning supplies, sharps, and a complete first aid kit. Another locked closet by the front door contained medications and confidential files.

LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition. The outdoor space contained a maintained yard area, games, a television, and puzzles. The emergency exit paths was free from obstructions. Two (02) out of two (02) exit gates were unlocked. The front and rear door