Facility Evaluation Report

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

The facility is a single level structure and licensed for six ambulatory clients. As of today, the facility has six clients admitted to the facility. All six clients were at day program at the beginning the visit. Near the middle of the visit four of the clients returned from their day program. There’s a total of five bedrooms, of which three bedrooms are for the clients, and two bedrooms are for staff. There are two restrooms available. There’s a living room space, a dining space, backyard, office area, and a detached garage. Bedrooms: All bedrooms were clean and organized and had the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. No chemicals observed in the bathroom. Kitchen: 4 of 4 burners and the warmer are operational on the gas stove. Sharps are kept locked cabinet across from the stove. Chemicals stored in the locked cabinet directly under the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed in the kitchen, and the pantry area.

Client & Staff Files : Client and staff files stored in the main office area behind the dining table in a locked cabinet.

File Review: Client and staff files were reviewed and all necessary documents were observed.

Medications/First-Aid Kit: Client medications are stored in a locked medication cart. Two first aid kits are stored in a locked cabinet in the kitchen.

Medication Review: Client medications were reviewed during the visit. Medications are being administered as prescribed. No discrepancies were noted.