Facility Evaluation Report

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry by Administrator Phyllis Edwards and Gwendolyn Nicole O'Neal.

The facility is a one-story home with three resident bedrooms, one bathroom, kitchen, dining room, living room, staff room, back yard and attached two-car garage. LPA observed a hole in the wall in the garage, a drawer in the kitchen that was missing a door and a light switch in the bathroom that did not have a covering for the light switch. A deficiency is being issued on this day. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Upon first measuring hot water, it measured over 120 degrees Fahrenheit. The Administrator lowered the temperature on the water heater. Hot water took 90 minutes to cool down. Restroom hot water measured at 110.3 degrees Fahrenheit. LPA observed exit gates in the backyard to be operational and unobstructed. Facility has one shaded seating area in the backyard. Smoke and Carbon Monoxide detectors tested operational. LPA observed facility has emergency food and water supply. Appliances are operational. Facility has a 2-day supply of perishable food and a 7-day supply of non-perishable food. Fire Extinguisher was observed to be fully charged as indicated by the built-in meter. The service tag indicates it was last serviced on 10/12/23. LPA observed client medication and staff files to be locked in the office and clinical room. LPA reviewed medication and files for both clients. LPA observed clients’ health screenings were not in file. LPA also reviewed P&I. One of the three P&I reviewed was short by $200. Facility staff corrected this during the inspection. While reviewing files, LPA noted that the Infection Control Plan was not kept on file. LPA issued a technical violation. LPA also noted that the facility has conducted emergency drills in 2023, but the drills did not occur at least quarterly. LPA issued a technical violation. LPA reviewed two staff files. All clients were away at day program.

Based on today’s inspection, three deficiencies and two technical violations were issued. An exit interview was conducted and a copy of this report was provided.