Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 1:00 PM, LPA Tea was greeted and granted entry into the facility by Assistant Administrator (AA) Aubri Griffis. Facility is licensed for 2 non-ambulatory clients. Currently there are two clients during today's visit.

At 1:15 PM, LPA Tea reviewed two client files and five staff files. Client files and staff files contained all required documentation apart from one resident who, just recently got medical insurance coverage. The staff are currently trying to obtain an updated physician’s report. AA Griffis’s certificate expires April 12, 2026.

LPA Tea along with the AA Griffis’s and Lead PT Carla Ibarra toured the facility at 2:22 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a one-story home with two client bedrooms, two bathrooms, a staff office room, a vocational room, living room, laundry area, dining room, kitchen and detached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident 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, grab bars were secure, and shower was free of mold/mildew. Water temperature measured around 110.8 degrees F. 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. There are cameras in the common area, recording video with no audio for safety purposes. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in box and double locked in a kitchen cabinet. LPA also observed toxin substances to be secured and locked and inaccessible to clients underneath the kitchen sink.