Facility Evaluation Report

Licensing Program Analyst (LPA) Fred Arias arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA was greeted and granted entry and met with Administrator (AD) Bob Henning.

The facility is a two story structure. The client census is sixty-eight (68) and fourteen (14) staff are present.

LPA toured the two floors accompanied by AD. The second floor is reserved for staff offices. LPA observed the following areas on the first floor: client work space, restrooms, isolation room, cleaning supply room, computer room, and office spaces. LPA observed all areas to be clean, sanitary, and operational. The furniture were in good condition. All restrooms observed to have sufficient supply of soap, toilet paper, and paper towels. Hot water measured within the range of 111.3 and 112.4 degrees Fahrenheit in the two client restrooms checked. LPA observed the temperature of the first floor at 72 degrees Fahrenheit. LPA observed clients participating in activities. LPA observed fire and sprinkler systems were inspected quarterly and were maintained in conformity with the State Fire Marshal per inspection report dated 03/31/2025. Fire extinguishers were observed to be mounted and charged. Emergency drills are conducted quarterly with the last drill conducted on 04/10/2025. Disinfectants, cleaning solutions, and sharp were inaccessible to the clients in care. LPA observed the emergency disaster supplies and food/water in the outdoor shed. LPA observed an outside garden area for clients to plant vegetables in close to the shed. Facility does not handle medications.

LPA conducted a review of five client files and five staff files. Client files contained all required documentation including admission agreements, physician reports, personal rights, consent forms, and face sheets.