Facility Evaluation Report

At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual inspection. The facility was locked, and LPA contacted the Administrator via phone and disclosed the reason for the visit. Administrator arrived at the facility at 9:55 AM. Physical tour was conducted with the Administrator at 10:00 AM, and LPA observed the following:

Kitchen: At approximately, 10:00 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen drawer. At 10:05 AM, LPA observed a fully charged fire extinguisher in the kitchen and last serviced on 02/17/2025.

Medications: At approximately, 10:06 AM LPA observed medications are centrally stored and locked near the kitchen in a standing cabinet.

Bedrooms: The facility is fire cleared for four (4) ambulatory clients. The facility has four (4) private bedrooms. Two (2) out of four (4) bedrooms are vacant. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff.

Bathrooms: LPA observed two (2) bathrooms for clients use and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 10:10 AM, Hot water temperature measured at 112.1°F. LPA observed an additional bathroom for staff use only and was locked and inaccessible to clients in care.