Facility Evaluation Report

Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to the facility today to conduct

required 1 year inspection. During today’s visit, LPA met with Administrator Marie Noel and explain the

purpose of today's visit. LPA Frank toured the facility, which included: Living room, dining area, kitchen,

laundry room, 4 bedrooms and 2 bathroom, shaded area, indoor/outdoor activity areas, reviewed

medications; medication records, food service, clients and staff records.

The facility is a one story house which is Licensed for Adult Residents five ambulatory clients Ages 18 to 59

Years. Currently 4 clients are in care. Each resident bedroom is equipped with the proper furniture and linen

In addition, LPA Frank tested the hot water temperature, which measured 107.1 degrees F in resident

bathroom. Resident areas were noted to be a comfortable temperature.

Smoke detectors and carbon monoxide detectors were tested and found to be operational. The facility also has fire extinguisher that was mounted and charged. LPA Frank confirmed food supply: 2 day supply of

perishables and 7 day supply of non-perishable food is available for the number of residents present.

Hygiene supplies and supply of linen were observed in quantities for the number of residents in care.

Body of water on premises was secured. The ramp leading from a client room to the backyard has extensive rot which could lead to injury to client(s) in the event of a collapse.

LPA observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet.

LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log,

LPA observe the facility to be clean and in good repair. Physical Plant and Safety of Environment/Operational

LPA Frank reviewed : 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report

(LIC500); 3.) Emergency Disaster Plan (LIC610E); 4.) LIC 9020A Client Roster; LIC 808) Mitigation Plan;

Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.

This report was discussed with the facility representative and a copy was provided .