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, and all four clients were present at the beginning of the visit before two went to their day program. There’s a total of 6 bedrooms, of which 4 bedrooms are for the clients, one bedroom is currently vacant and is being used mainly as an overflow storage area, and there’s one staff room. There are two restrooms available. There’s a living room space, a dining space, activity area, and a detached 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: All burners on the gas stove were operational. Sharps are kept in a locked cabinet below the countertop. Cleaning chemicals stored in the locked cabinet directly below the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed in the kitchen, and the pantry area.

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 four staff files were reviewed.

Medications/First-Aid Kit: Client medications are stored in a locked medication cabinet in the dining room area. A first aid kit and additional first aid supplies was observed in a locked cabinet in the kitchen.

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