Facility Evaluation Report

On September 12, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using CARE Tools. Upon arrival at the facility, LPA Bentley was greeted and granted entry into the facility by staff after stating the purpose for the visit. The Administrator (AD) Kim Southern was contacted by telephone, arrived a short time after, and remained throughout the visit. The facility is a single-level structure licensed for six (6) ambulatory clients, age 18 through 59 and offers Adult Residential Care.

LPA Bentley conducted a tour of the physical plant accompanied by AD Southern and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and bedding supplies were available, lighting was provided in all rooms, and storage for the client's personal belongings were observed in clients’ closets and drawers. Additional bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperatures measured at 105.4 degrees F and 110.1 degrees F. Smoke and carbon monoxide detectors were tested and operational.

All client bedrooms were clean, well-organized, and had all the necessary items and storage space. The kitchen was clean and organized. A two-day supply of perishable food items and seven-day supply of nonperishable food items was observed in cabinets. All appliances are operational during today's visit. Medication is stored in a locked cabinet in the kitchen. There is a washer and dryer in an area near the kitchen and both were found to be in working condition. Knives and sharp objects were unlocked in a drawer under the stove. Hazardous cleaning chemicals were found unlocked in a cabinet, under the sink. Additional sharps and toxins were observed unsecured in Bathroom #1. A deficiency is being cited.