Facility Evaluation Report

Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caregiver Sean Smith and Licensee Shirley Smith who were informed of the purpose of the visit. The facility has a fire clearance for two (2) ambulatory clients and serves adults ages 18 through 59 years of age. LPA was notified that the two (2) clients were attending the day program.

LPA toured the facility and reviewed records. During the tour, LPA observed the facility is made up of a two-story home with three (3) client bedrooms, two (2) staff bedrooms and three (3) bathrooms, a living room, dining room, kitchen, and attached garage. All client bedrooms had the required furniture, lighting, and closet storage. LPA toured the facility's exterior and observed outdoor pathways were free of obstructions. LPA toured the kitchen and observed the facility has a two-day supply and perishable foods and more than a seven-day supply of non-perishable foods that were observed to be properly stored and readily available. Knives and sharp instruments were secured in a locked cabinet located in the laundry room. LPA toured the garage and observed a second refrigerator with additional perishable food. LPA reviewed random client and staff records. Client files reviewed had updated Individual Program Plans and signed admission agreement. Staff files reviewed had the Department's required training records and valid first aid/CPR certification. LPA reviewed the facility's Fire Drill logs and noted the facility's last fire drill was conducted on 02/08/25 . LPA reviewed the physical medications and Medication Administration Record for two (2) clients and did not discover any discrepancies. LPA also observed that the laundry room was locked and had a cabinet that is filled with additional cleaning solutions, disinfectants, and laundry detergents. LPA also observed additional clean towels, blankets, and linens for the clients stored in the hallway closet.