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 clients, of which 2 may be non-ambulatory. As of today, the facility has three clients admitted to the facility. One clients was present at the beginning of the visit and the other two clients were at their day program. The facility has a total of 7 bedrooms, three for the clients, 1 for staff, and 3 vacant rooms. There are two restrooms available for the clients. There’s two living room spaces, a dining space and a 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. Hot water measured in between 105.9 – 118.5 degrees F. Kitchen: 5 of 5 burners were operational on the gas stove. Sharps are kept in a locked toolbox below the stove. No cleaning chemicals are stored in the kitchen. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed.

Client & Staff Files : Client and staff files are located in the staff office area.

File Review: 2 of 3 client files were reviewed during the visit, and 3 staff files were reviewed.

Medications/First-Aid Kit: Client medications are stored in a locked closet near the front door. There’s a commercial style first aid box mounted to the wall in the office area behind the main desk.

Medication Review: 2 of 3 client medications were reviewed during the visit. No discrepancies observed. Medication’s are being administered as prescribed.