Facility Evaluation Report

On August 3, 2026, at 9:00 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 Assistant Clinical Director Ashley Southard and explained the purpose of the visit.

The facility is licensed to operate for six (6) ambulatory clients. The facility is a two-story building located in a residential neighborhood. It consists of the following: four (4) client bedrooms, two (2) bathrooms, one office area, living area, dining area, art area, kitchen, and attached 3-car garage.

LPA toured the indoor and outdoor physical plant. 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 between 141.9 degrees Fahrenheit to 144.6 degrees Fahrenheit in all client bathrooms. 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 garage. 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 that were inspected on June 22, 2026. Medications, sharps, and toxins were locked and inaccessible to the clients.

The following items were all posted and available for review: Emergency Disaster Plan (LIC610D), food menu, and client rights. Evidence of liability insurance was effective October 20, 2025, to October 20, 2026. Emergency Drills are conducted monthly and last conducted on July 31, 2026.