Facility Evaluation Report

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:15AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit. House Manager arrived shortly after.

LPA and House Manager initiated a tour of the facility around 09:45 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 108 degrees F which is within the range of 105 to 120 degrees F allowed per regulation.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Client medications were centrally stored and locked. LPA observed a staff members prescription amoxicillin in bathroom #1 cabinet. LPA observed cleaning supplies underneath bathroom #1 sink. House Manager confirmed that clients do not generally use bathroom #1, however it is always accessible to them if needed. House Manager removed the medication and secured the cleaning supplies under the kitchen sink.

Emergency food and water is stored in the garage. Personal Protective Equipment is stored in the hall closet. Fire extinguishers were last serviced February 13, 2024. Facility smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 07/03/2024. Client cash resources were reviewed. Five staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Administrator Certificate for House Manager, Cluvens Deliska (6070053735) is on the departments pending list.