Facility Evaluation Report

At approximately 9:15 a.m. on 08/02/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an announced pre-licensing inspection. LPA met with the Program Director and Clinical Director and disclosed the reason for the visit. LPA and Directors toured the facility inside and out.

It is a two story building with five (05) bedrooms, six (06) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) ambulatory clients.

At the main entrance, LPA observed a maintained front entrance and driveway. Postings were observed for the activity schedule, weekly menu, clients rights form, rights of resident councils, confidential complaint information, facility sketch, and Public Health License and Clinical Laboratory Certification. The Emergency Disaster Plan was posted in the medication room.

Walls, floors, windows, screens, and blinds were clean and in good repair. The front and rear activity rooms contained new furniture in good repair, activities, board games, a ping pong table, televisions, and a covered fireplace. At 9:25 a.m. LPA measured the room temperature to be 76 degrees Fahrenheit. Cameras were observed in common areas and the exterior.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator, freezer, and pantries. The stove hood was clean. Appliances were new and sanitary. Sharps were locked in a lock box in a drawer. At 9:30 a.m. the refrigerator and freezer temperatures were measured to be 36 and 0 degrees Fahrenheit, respectively.

At approximately 9:40 a.m., smoke and carbon monoxide detectors were tested and operational. Auditory alarms were turned on and functioning. At approximately 9:45 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 02/12/24. Two (02) out of two (02) emergency exit pathways were free of hazards with unlocked exit gates.