Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted a follow up visit to continue the annual inspection. LPA arrived unannounced and met with Staff, Sidie Koromah. The purpose of the visit was explained. The initial inspection began on 4/22/25.

LPA continued the inspection using the CARE tools and the remainder of the domains were reviewed:

Staffing: The facility has sufficient staffing to cover all shifts and one staff awake at night to supervise clients.

Personnel Records-Training : LPA reviewed the administrator and 2 other staff files. The files have the required documents such as health screening with TB results and current CPR/First Aid certificates. Staff have sufficient training to provide care and supervision to clients.

Client Rights - Information : There are no clients who utilize postural supports. The facility provides internet access.

Client Rights - Incident Reports: LPA reviewed 4 client files. The files contained the admission agreement, medical assessment with TB results, annual IPP reports, consent forms, and client rights form.

Incidental Medical Services: There are no clients who are insulin-dependent diabetic.

Disaster Preparedness: The facility has an updated Emergency Disaster Plan which includes emergency contact numbers, at least 2 appropriate shelter locations, and utility shutoff valves. Facility is conducting quarterly disaster drills.

No deficiencies were issued today. An exit interview was held and a copy of this report was given to the staff S. Koromah.