Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA knocked on door and no answer. LPA contacted Director of Quality and Compliance Catherine Mann by telephone who stated would be at facility shortly. At approximately 12:05 PM, LPA was greeted and granted entry by Catherine Mann and Administrator Greg Rosenbaum and explained the reason for the visit.

Facility is licensed for six ambulatory clients and there are four clients currently admitted to the facility. Upon entry, facility appears clean, safe and sanitary.

LPA Lyman along with Administrator and Director of Compliance toured the facility at 12:30 PM. LPA toured the physical plant, checked food service, and reviewed facility documentation. The home consists of two stories with two client bedrooms, two client restrooms, common restroom, living room, dining room, and kitchen on the first floor and one bedroom, client restroom, patio and a second separate client bedroom/ restroom off a second patio. 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 111.5 and 114.9 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 09/16/2024 and drills are conducted quarterly. Facility provides activities in the form of exercise and community outings. LPA reviewed four client files and four 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. CONT ON LIC 809C DATED 12/09/2024