Facility Evaluation Report

Licensing Program Analyst (LPA) Bernadette Allen arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with Pat Duncan Administrator and explained the purpose of the visit.

The facility is licensed for 60 ambulatory and 20 non-ambulatory for a total of 80 clients. LPA toured the facility inside and out with the Pat Duncan.

LPA observed activity rooms for arts & crafts, card games, cooking, grooming, work opportunities, and education. There are no firearms on the property. The facility has charged fire extinguishers and carbon monoxide detectors. The facility has a fire alarm system that is tested yearly. The facility has safe and healthy indoor activity space for clients.

The outside of the facility has shaded area and seating. LPA observed a basketball court and a gardening section. Cleaning supplies, knives, and toxins were locked and kept inaccessible to clients. Client restrooms were maintained in a safe and sanitary condition. LPA measured the hot water temperature in the client restrooms. The water temperatures measured 105-120 degrees F.

The facility provides snacks for the clients. The snacks were stored in a safe and healthful manner. The last emergency disaster drill was conducted on 10/2024. The facility was equipped with a complete first aid kit including a manual.

LPA reviewed staff and client files. Staff files had appropriate documentation including current first aid/CPR certification and a health screening reports and trainings. Client files had appropriate documentation including identification/emergency information, IPPs/needs service plans, and admissions agreements. The facility does not administer medications and they do not handle P&I funds.