Facility Evaluation Report

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year Inspection using the Care Inspection Tool. LPA was greeted and granted entry and met with Administrator (Admin) Chelsae Mansfield and Director of Operations (DOO) Bob Henning. Administrator Mansfield has a valid certificate expiring August 21, 2026.

The following was observed during the tour accompanied by Admin Mansfield: The facility is a two story structure. There are sixty-five (65) clients and nineteen (19) staff present. The fire clearance is approved to serve twenty-five (25) non-ambulatory clients. Facility is operating within the conditions and limitations specified on the license. LPA observed all areas on the first floor which includes, client workshop space, computer room, 3 client bathrooms, medication/isolation room, staff break room, cleaning supply room, and office spaces on the first floor. The second floor also houses office spaces and two bathrooms designated exclusively for staff use. LPA measured the hot water temperature in the three client bathrooms on the first floor. The hot water temperature measured at 111.9 in the women's, 113.7 in the men's, and between 99-102 degrees Fahrenheit in the all gender bathroom. One of the three client bathrooms was found to have hot water temperature outside the acceptable range. The water heater could not be further adjusted because it had already reached the maximum temperature setting of 120 degrees Fahrenheit. As a precautionary measure, the bathroom will be closed off limits to clients until a new water heater is installed and proper temperature can be maintained between 105 to 120 degrees Fahrenheit per DOO Bob Henning. All restrooms observed to have sufficient supply of soap, toilet paper, and paper towels. The furniture were in good condition. Based on observation, all areas were observed to be clean, sanitary, and in good repair. LPA observed the sprinkler systems were inspected quarterly and the smoke/carbon monoxide detectors were tested and passed on January 13, 2026.