Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Administrator Jacques Scutt. Clients were present during the visit. There is no day program at this time due to short staffing for one on one care for clients at Adult Day Program.

Upon arrival, LPA confirmed with Administrator that they are following current Covid19 and masks guidance. LPA/Administrator initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 105.8 which are within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet in the garage. Medications are centrally stored in locked boxes. Fire extinguishers were last inspected March 2023. Smoke detectors and carbon monoxide detector located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 5/5/23. Facility does have a current activity calendar. Required postings were observed. First aid kit was fully stocked.

LPA initiated a file review at 12:00 pm. Four clients and four staff files were reviewed. Clients records have updated care plans on file. First aid certificates for staff are current. Administrator Certificate for Jacques Scutt 6010925735, expires October 2023. Medications and medication records were reviewed. Cash resources documentation were reviewed.

LPA obtained updates of the following documents: LIC308 (Designation of facility responsibility), LIC400 (cash affidavit for clients) and LIC610D - Emergency Disaster Plan.

No deficiencies cited during today's inspection. Exit interview conducted with Licensee/Administrator and a copy of this report was given.