Facility Evaluation Report

01/08/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. There are currently six clients in care. LPA was greeted by Relief Manager, Teresa Thomas. Upon arrival, one client was present and five clients were attending day program.

LPA and Relief Manager toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. LPA observed expired canned food in the pantry located in the garage with expiration dates from 2024 and 2025 (Technical Violation Issued). LPA and Relief Manager did not observe complaint poster to posted, Relief Manager ensured LPA they will print out required posting and have it posted.

All rooms were furnished per regulation. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured and found to be within the range of 105 to 120 degrees F. Fire extinguishers were last inspected February 2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were located in the kitchen and hallway closet and were found to be secured. Medications were found to be centrally stored. LPA conducted spot medication count and found medications expiration date to not be accurate with what is on the centrally stored medication log and the date filled to be empty (Technical Violation Issued). Facilities last emergency drill was conducted May 2025.

LPA conducted a review of three client records. All records had the required documentation. Client P&I monies were reviewed. LPA conducted review of three staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.