Facility Evaluation Report

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

The facility is a single level structure and licensed for six ambulatory clients. As of today, the facility has four clients admitted to the facility. Three clients were present during the visit. There’s a total of 6 bedrooms of which 4 bedrooms are for the clients, one bedroom has been converted into activity area and one empty room is being used as a storage area. There are two restrooms available. There’s a living room space, a dining space and an attached garage. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. No chemicals observed in the bathroom. Kitchen: 4 of 4 burners and the warmer were operational on the gas stove. Sharps are kept locked in a cabinet below the counter next to the chemicals stored in a locked cabinet directly under the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed in the kitchen.

Client & Staff Files : Client and staff files stored in the main office.

File Review: 3 of 4 client files were reviewed during the visit, and three staff files were reviewed.

Medications/First-Aid Kit: Client medications are stored in a locked medication closet. Inside the locked medication closet, first aid supplies were observed.

Medication Review: 3 of 4 client medications were reviewed during the visit.