Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by staff. CFO Max Reznik and Administrator Greg Rosenbaum arrived during the visit. Facility is licensed for six ambulatory clients. There are 6 clients present during today's visit. Upon entry, facility appears clean, safe and sanitary.

LPA Lyman along with Max Reznik toured the facility at 8:10 AM. LPA toured the physical plant, checked food service, and reviewed facility documentation. The home consists of two client bedrooms downstairs and a staff restroom with four client bedrooms and four client restrooms upstairs, living room, dining room, and kitchen. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 111.3 and 119 degrees F in facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for clients. Exit gates are unlocked and operational. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. plan is thorough and complete. Facility provided documentation of last fire drill conducted on 10/08/2024 and drills are conducted quarterly. Facility provides activities in the form of exercise and community outings. LPA reviewed six client files and two staff files during the visit. Client files contained all required documents. Staff files reviewed contained required documentation of training and all pertinent paperwork including CPR/ First aid. LPA reviewed medication storage and administration. Medications are stored in a locked medication room and are being administered per physician order.

Based on the observations made during today’s visit, NO deficiencies are being cited. This report was discussed with the facility representative and a copy was provided.