Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Facility is licensed for six ambulatory clients and there are three clients currently admitted to the facility. Upon entry, facility appears clean, safe and sanitary.

LPA Lyman along with Client Coordinator Sherif Armanious toured the facility at 10:08 AM. Facility management team joined the tour in progress. LPA toured the physical plant, checked food service, and reviewed facility documentation. The facility consists of three stories with one client bedroom/ restroom and therapy room on the third floor, living room, dining room, kitchen, staff restroom and two client bedrooms/ restroom on the main second floor and medication room on first floor. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 110.8 and 116.6 degrees F in facility restrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, scissors and thermometer as well as a first aid manual. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility chef prepares lunch and dinner and clients prepare their own breakfast. At 10:20 AM, LPA observed kitchen cupboards are scratched and discolored as well as the door to staff restroom and garage is in need of cleaning. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. LPA observed an emergency evacuation chair at stairwell. LPA toured the outside grounds and there is a pool secured with safety netting. CONT ON LIC 809C DATED 07/16/2025