Facility Evaluation Report

On 08/26/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Direct Support Professional II, Jonathan Francis, and the Administrator Tyheara Marrow-Tyars arrived shortly after. At the time of the visit there was (2) staff and (1) client present, and then left to work, the other (2) clients were day program. Below is a summary of what was observed:

The facility was observed to be clean, clutter and odor free.The facility was observed to have extra linen, and personal hygiene supplies. The medications, chemical, and other hazardous items were observed to be locked and inaccessible to clients in care. The emergency disaster drills are being conducted on a monthly basis, the last drill conducted was on 08/05/25. The fire extinguishers were last serviced February 18, 25. The smoke and carbon monoxide detectors were tested and found to be operable. The water tested and found to be within regulatory limits measuring at 117.3 degrees Fahrenheit. The food supply was observed to be adequate, as there was a 2 day supply of perishable and a 7 day supply of non perishable food items.

LPA reviewed all clients files, the files were observed to have the proper documentation such as admission agreement, Individual Program Plan (IPP) and medical assessment. Staff files reviewed were observed to have have criminal record clearance and to be associated to the facility. Staff were observed to have valid CPR certification. Tyheara Marrow Tyars, Administrator’s certificate expires on 04/14/26. The annual fees have been paid, and the governing body is in good standing. LPA verified contact information for the facility with no changes needed.

Based on today's inspection no deficiencies were observed. An exit interview was conducted and a copy of this report was reviewed and provided to Tyheara Marrow Tyars.