Facility Evaluation Report

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by facility staff. LPA met with Maxine Kniazeff, Assistant Administrator and explained the purpose of the inspection.

The facility is one-story building with 6 client rooms, 2 client bathrooms, kitchen, dining room, living room, two offices, staff bathroom, family room, backyard and 2-car garage. All client rooms had the required elements, including bed, chair, closet space and ample lighting. LPA observed the facility to be in good repair. LPA observed one exit gate that are self-latching and unlocked. Facility has toxins, chemicals and cleaning supplies locked in a cabinet in the laundry area. LPA observed an uncovered bowl of meat in a refrigerator accessible to clients. A deficiency is being issued. Facility staff immediately covered the bowl with saran wrap and wrote "For Staff" on the wrap. LPA observed sharps to be locked in a drawer in the kitchen. Restrooms are stocked with soap and paper towels. LPA observed facility has emergency food and water supply as well as additional emergency supplies. LPA observed the fire extinguishers are full as indicated by the arrow pointing in the green zone on the meter. LPA observed the service tags on the extinguishers stating they were serviced on October 2, 2024. LPA reviewed 7 staff files and 4 client files. LPA reviewed the P&I and medication for all clients. Based on medication review, LPA observed one prescription for one client to have no label. A deficiency is being issued. LPA conducted interviews with 2 staff. Clients present were non-verbal and unable to be interviewed by LPA. LPA observed the facility to have the necessary postings including a menu and activity calendar. LPA observed facility has games, electronics, art supplies and exercise equipment for client use.

Based on today's inspection, two deficiencies are being issued. An exit interview was conducted and a copy of this report, deficiency page and appeal rights were provided to the facility.