Facility Evaluation Report

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that seven (7) clients live at this facility, there were six (6) clients present at the home, at the time of the inspection. There was six (6) staff members present. The Clinic Director, Marcia Lewis conduct and completed the facility tour. LPA Banrasavong spoke to the Licensee, Chris Spencer on the phone during the annual inspection. The Psychiatric Nurse Practitioner, Elizabeth Anyanwu completed the annual inspection.

Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Seven (7) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/ Staffing/ Administration : LPA reviewed employee records. Six (6) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Chris Spencer does not possess a current Administrator’s certificate or the required the training hours.