Facility Evaluation Report

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for six ambulatory clients with three clients living at the facility.

LPA along with staff toured the facility at 9:25 AM. LPA toured the physical plant, checked food service, and facility documentation. The facility consists of two stories with four client bedrooms, three restrooms on the bottom floor, living room, dining room, kitchen, nursing station, multiple therapy rooms and one restroom on the main floor. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. LPA observed evacuation chair. Client bathrooms were checked. Toilets and water faucets worked properly and shower was free of mold/mildew. Water temperature measured between 117.6 degrees F and 119.3 degrees F in all bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. LPA observed sharps locked in a closet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 5/19/2026. Outside grounds were toured. Walkways around the home were clear of hazards. LPA observed a fenced jacuzzi with seating for clients. LPA observed the emergency food and water supply. First aid kit contained all required items including tweezers, scissors and thermometer. LPA reviewed three client files and four staff files.