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 four clients currently admitted to the facility. Upon entry, LPA observed the facility temperature was 55 degrees F.

LPA Lyman along with Compliance Coordinator Kerri Bamper toured the facility at 8:00 AM. Clinical Director Kristian Concepcion joined the tour in progress. LPA toured the physical plant, checked food service, and reviewed facility documentation. The home consists of three stories with three client bedrooms on the third floor, living room, dining room, and kitchen on the main second floor and one therapy room/ restroom on the 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 92.3 and 103.7 degrees F in facility bathrooms. 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. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is an outside smoking area for clients. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 01/13/2025 and drills are conducted monthly. Facility provides activities in the form of exercise and community outings. LPA reviewed four client files and four staff files during the visit. Client files contained all required documents. Staff files reviewed contained required documentation of training and all pertinent paperwork including CPR/ First aid. LPA reviewed medication storage and administration. CONT ON LIC 809C DATED 02/10/2025