Facility Evaluation Report

Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced visit to the facility for the purpose of an annual inspection. LPA was greeted and granted entry by Administrator, Tammy Enos. Director, Angelica Hill arrived shortly. A tour of the facility was conducted inside and out.

The facility has no bodies of water or firearms. Outdoor and indoor passageways were kept free of obstruction. The facility currently does not dispense medications. LPA observed safe and healthy indoor activity space for the clients. LPA also observed designated areas where activities such as exercise, dancing, arts and learning activities take place. LPA observed several complete first aid kits throughout the facility and the last disaster drill conducted was on 7/24/2023. The facility has charged seven (7) fire extinguishers. Fire alarms and carbon monoxide detectors were tested and found operable. Appropriate signage was posted throughout the facility. Indoor temperature measured 70 degrees F.

LPA toured the kitchen areas. The facility provides snacks for the clients. LPAs observed that snacks are stored in a safe and healthful manner. Cleaning supplies and sharps were kept locked and inaccessible to the clients. LPA toured the client bathrooms. Bathrooms were maintained in safe and sanitary conditions. LPA measured the hot water temperature in the bathroom. The hot water temperature measured 111.4 degrees F.

Staff and client interviews were conducted. LPA reviewed staff and client files.

Staff files had the required documentation including a health screening report and current first aid/CPR certification. Client files had the required documentation including an admission's agreement and updated IPP's.

During today's visit, LPA did not observe any deficiencies. A copy of this report was discussed and provided to Director, Angelica Hill.