Facility Evaluation Report

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced annual required visit. LPA arrived to the facility and was greeted by Administrator Bob Henning, and explained the nature of the visit.

At 9:15am LPA accompanied by Administrator began the tour of the day program. LPA observed that the facility has designated areas for different activities which include but are not limited to isolation room, nurse’s station/health related services, and activity rooms. LPA observed activities and participation by clients. Today's activities include reading, arts and crafts, and motor skill development. The facility has a private changing area for clients use, 2 restrooms in the first floor and 4 restrooms in the second floor. LPA tested the hot water temperature in three restrooms and the measurements were between 115.3 and 118.4 F. During the tour, LPA did not observe any items accessible to clients which would pose a risk to their health and safety. Medication is locked and stored in nurse’s station inaccessible to clients in care. LPA reviewed medication administration. The facility maintains a locked location for chemicals and toxins. LPA observed an outdoor area designated for clients use with picnic tables and swings for clients. LPA observed two vehicles being loaded with clients for outings. LPA observed 2 evacuation chairs by the stairway closest to the elevator. Evacuation plan, client’s rights, facility license and emergency disaster plan are posted on the first floor. LPA reviewed the infection control plan. LPA was provided with fire safety maintenance records dated 12/30/2024. Fire extinguishers are charged and mounted throughout the facility. Fire/disaster drills are conducted quarterly. The last fire drill was dated 04/10/2025. LPA reviewed six staff records assessing for training logs, first aid/CPR, criminal record clearance, personnel record job application, health screening and TB test results, criminal record statement, and employee rights.