Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in the facility. Via phone LPA spoke with Licensee Kevin Clark; and stated the purpose of this visit.

At 8:41 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedures. LPA observed two clients in care and three staff members on the floor ( The third staff was the outgoing night staff). One client was later picked up by the day program. Per interview with Licensee, another client moved out and transferred to affiliated licensed facility effective July 1, 2022.

At 9:21 AM, LPA conducted a tour of the interior and exterior portion of the two level facility. Facility is licensed 4 ambulatory. On the upper floor are the three client rooms (Client 1 and two empty rooms). Rooms were provided with bed furniture, clean linens, storage cabinets, and table. The upper bathroom was provided with a bath tub, and water fixtures in good repair. Hot water was measured at 115 degrees Fahrenheit. In the lower level is another client's room which was provided with bed furniture lined with clean linens, a recliner and storage cabinet. Lower bathroom was provided with walk in shower area and water fixtures in good repair. Hot water was measured at 114 degrees Fahrenheit. LPA tested the hardwired smoke and carbon monoxide alarms and were observed to be operational. Fire extinguisher was mounted and charged. Locked medication cabinet contained client's medications, records, sharp kitchen items, and first aid kits. For the kitchen, facility met the minimum 2 day perishable and 7 day non-perishable food stock requirements. For the exterior portions, LPA observed self latching side gates, and patio furniture in good repair. After the tour, LPA reviewed the medications for Client 1 and Client 2. Administrator Kenneth Leonard certificate is valid until 1/6/2024.

For this visit, the following deficiencies were observed: At 9:22 AM, inside Client 1 room was an office chair with torn fabric on arm rest; and chair was leaning towards the left. At 9:36 AM, in the garage area converted as audiovisual or game room, the plastic storage cabinet that held cleaning supplies was in disrepair. Holes intended for padlocks were worn out; and doors can be opened without unlocking the locks.