Facility Evaluation Report

On 5/2/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a post-licensing inspection utilizing the care tool. LPA met with caregiver, who contacted Administrator who arrived to the facility after facility tour was conducted. Note: Time of visit was extended due to a break during the visit.

During today's inspection, LPA and Caregiver conducted a tour of the interior of the facility. LPA observed the presence of two clients in care. LPA was informed the other two clients are at adult day program. LPA observed medications to be locked. LPA informed caregiver to ensure key to locked cabinets are stored in an area inaccessible to clients and/or in caregiver's possession at all times. LPA did not observed sharps to be in the kitchen, LPA was informed sharps were kept in staff room. LPA observed chemicals and other toxins to be locked in the cabinet next to the laundry room. LPA observed laundry room to be free of detergents. LPA observed fire extinguisher to be serviced on 6/14/23. LPA observed documentation of fire drill to be conducted on 1/21/24; 2/12/24; 3/27/24; and 4/21/24. LPA observed the facility to have ample supply of nonperishable and perishable foods. LPA and Administrator discussed the possibility of change of facility use from adult residential facility to residential care facility for the elderly.

File review conducted for C1, C2, C3 and C4. LPA completed the post-licensing care tool and found facility to be in substantial compliance.

At this time, Administrator stated no concerns at the facility. No deficiencies cited.

Exit interview and a copy of report was provided.