Facility Evaluation Report

At 8:45 a.m. on 08/16/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit. LPA and administrator toured the facility inside and out.

The facility was last visited on 09/01/22 for a prelicensing visit. It is a single story building with four (04) bedrooms, four (04) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) ambulatory residents. Cameras were used in common and exterior areas.

At the main entrance, LPA observed postings for the neighborhood complaint policy. The driveway and front yard area were maintained. Additional postings were observed inside for the facility license, facility sketch with evacuation routes labelled, emergency disaster plan, confidential complaint contacts, ombudsman contacts, COVID precautions, personal rights, house rules, clinical license, visitation policy, and emergency contacts. A screening station had a visitor log and masks. Walls, floors, windows, screens, and blinds were clean and in good repair. Multiple indoor and outdoor fireplaces were observed. Fireplaces were turned off and appropriately screened. Shaded seating areas in the front and back yards had furniture in good condition. The back yard also contained exercise equipment, a designated smoking area, a fenced, locked, and inaccessible pool, three (03) grills, and two (02) detached offices. One (01) of the two (02) offices were locked. The garage was locked by a keypad and contained emergency water, PPE, hygiene supplies, chemicals and detergents, and a washer and dryer in good repair. At 9:20 a.m. LPA measured the temperature in the living room to be 72 degrees Fahrenheit. At 9:35 a.m. LPA observed two (02) fully-charged fire extinguishers in the kitchen. They were last inspected on 02/09/24. At 9:40 a.m. LPA measured the temperatures in the refrigerator and freezer to be forty (40) and zero (00) degrees Fahrenheit, respectively. Adequate supplies of perishable and non-perishable foods were observed in the kitchen and pantry. The stove hood was clean. Snacks and beverages were available in the dining area. Weekly and daily activity schedules were posted. Appliances were in good condition. Cleaners were locked below the sink. Sharps were locked in a closet labelled “Contraband”.