Facility Evaluation Report

10/07/2025 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Cheri Houlihan and explained the purpose of the visit.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to two (2) client rooms, common areas, one (1) bathroom, kitchen, storage areas and front yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current.

Recreational activities and outings are planned weekly according to the clients preferences.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area, kitchen, and bathrooms were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational. No pools/bodies of water are on premises. Last disaster drill was conducted in June 2025, the facility has been conducting fire drills every 3 months.

LPA requested the following documents that need to be updated in the facility file: Current administrator certificate, Emergency Disaster Plan, LIC500 Personnel report.

In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was provided to administrator Cheri Houlihan