Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit for a required annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA was greeted and granted entry by the Facility Manager Sheena Humphrey.

LPA toured the facility inside and out. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 4/28/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. LPA toured the client bathrooms. The hot water temperature measured above the required limits at 138 degrees Fahrenheit. Deficiency was issued. House Manager called the licensee Mr. Rush to adjust the water heater. The outside of the facility had a shaded area with seating for client comfort. The facility does not have bodies of water.

LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. LPA discovered the Administrators HIV/TB training was taken over 2 years ago, and is no longer valid. Technical violation issued. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA observed one clients’(C1) placement agreement was missing 80068(a)(1) objection of admission. LPA issued a technical violation. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.