Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Area Manager Tony Duarte. An initial application to operate an Adult Residential Facility was received by CCL on 03/18/2022 for a capacity of four ambulatory clients. Administrator Jennifer Hrabal arrived during the visit. Facility was previously licensed by Public Health as an Intermediate Care Facility. Licensee has surrendered the license.

LPA along with Administrator and Area Manager toured the facility at 9:11 AM and observed the following:

Structure: Facility is a two story, 5 bedroom, 3 bathroom house with an attached garage and a beige exterior. First floor has 2 bedrooms and two restrooms. Second story houses 2 bedrooms, one restroom and an office with an outside entrance. Living Room/ Dining Room : Adequate seating is available in the dining room and living room. Bedrooms Clients: Rooms will be single occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All client bathrooms have a working toilet/ wash basin as well as non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms. Linens & Hygiene Supplies: Facility has bedding, towels and hygiene supplies for clients in care. Emergency Phone Numbers and Exit Plan: Emergency plan/ phone numbers located in facility office. Food Service: Facility does not have 2 day perishables and 7 day non-perishables as there are no clients present. LPA observed ample emergency food and water. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins / Sharps : Facility has secured area for toxins/ sharps in garage. Water Temperature: Tested and recorded between 107.4 and 111.9 degrees F in all restrooms. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Kit contained a first aid manual. Facility to use a medication administration record. Client & Staff File: Records to be secured in the facility office. Reading Material, Games, and Equipment: Facility has an activity schedule including exercise, arts and crafts and bible study. LPA observed games and art in the facility. CONTINUED ON LIC 809C DATED 02/08/2023.