Facility Evaluation Report

At approximately 9:55AM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct an annual required inspection and was greeted by staff. Manager of Program Operations, Kayla Hotchkiss, and Acting Administrator Syed Hashmi, arrived at a later time.

LPA initiated a tour of the facility at approximately 10:15AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 124.5, 124.1,and 125.4 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation (see LIC809D). Extra hygiene products and linens were available. Additional cleaning supplies and disinfectants are stored in a locked closet which is inaccessible to clients in care. Facility has at least two days of perishable and one week of non-perishable foods which was stored per regulation and were of quality. Medications were centrally stored and locked. Emergency food and water supply are stored in downstairs office. Facility has a pool in the backyard that is fenced and inaccessible to clients in care.

Fire extinguishers were last serviced May of 2023. Facility has Smoke and Carbon Monoxide detectors located throughout the facility that were tested and operational during visit. Most recent fire/disaster drill was conducted July 28, 2023 (see LIC809D). Per conversation with Manager of Program Operations, it is understood that drills must be conducted every 3 months as per regulation.