Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA was greeted and granted entry into the facility 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 Director of Compliance Tracy Foust toured the facility at 8:29 AM. Director of Nursing Michelle Scott and Director Niloufar Nekou arrived during the visit. LPA toured the physical plant, checked food service, and reviewed facility documentation. The home consists of two stories with living room, dining room, kitchen, nursing station and one restroom on the main floor and three client bedrooms, therapy room and two restrooms on the second floor. There is an attached garage. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 116.1 and 118.2 degrees F in facility restrooms. 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 including tweezers, scissors and thermometer as well as a first aid pamphlet. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility utilizes a chef to prepare lunch and dinner. Clients make their own breakfast. 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 observed ample 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. CONT ON LIC 809C DATED 08/04/2026