Facility Evaluation Report

On March 13, 2026, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Program Director (PD) Marcus Nichols.

The facility is licensed to operate for six (6) ambulatory clients. The facility is a two-story house with five client bedrooms, two staff offices, therapist office, four bathrooms, a living room, a kitchen, a dining room, and attached two car garage. There is a backyard with a fenced pool, a covered above ground hot tub, and an exit gate each side of the house. LPA did not observe any obstacles in the backyard.

LPA toured the indoor and outdoor physical plant with PD Nichols. There was shading and sufficient seating for the clients. LPA observed that the client bedrooms had all required elements with ample lighting. Showers, faucets, and toilets were sanitary and in operating condition. The hot water temperature measured at 145.0 degrees Fahrenheit to 147.7 degrees Fahrenheit in client bathrooms. During the visit, the facility was able to adjust the water temperature to be between 118.0 degrees Fahrenheit to 118.2 degrees Fahrenheit. There was sufficient and clean supply of linens. LPA observed ample two-day supply of perishables and seven-day supply of non-perishables. LPA observed the emergency food and emergency water stored in the first floor office room. The carbon monoxide and smoke detectors were tested and operational. There are two (2) fire extinguisher that are securely mounted in kitchen and second floor hall. They were both inspected on September 15, 2025. Medications, sharps, and toxins were locked and inaccessible to the clients.