Facility Evaluation Report

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Administrator (AD) Devonda Nelson and the purpose of the inspection was discussed.

During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, staff rooms, kitchen, and observed the following:

This is a one-story home with three client bedrooms, two staff bedrooms, and three bathrooms. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. The backyard has a shaded sitting area. LPA observed clients arriving home from day program and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew and faucets and toilets were operational. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated November 12, 2025. Gas stove, microwave, and laundry washer and dryer were observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to clients. Medication was observed to be centrally stored and locked. Record review of clients’ safeguarded cash resources, Medication and Medication Administrator Records (MARs) were reviewed for five of five clients and no discrepancies were observed. LPA reviewed five of five client files and two staff files. LPA interviewed two clients, and one staff present.