Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/16/24 at 3:00pm. LPA met with Cherry Madamba and stated the purpose of the visit. The Administrator Certificate expired on 6/29/2025. Licensing fees are current. The facility is licensed for a total capacity of 6 residents.

Upon arrival residents were returning from day program. Facility has a Restricted Health Conditions Care Plan and Infection Control Plan on file. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F.

The hot water temperature was measured at 112.0 *F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed fire extinguishers, carbon monoxide and smoke detectors. LPA observed the centrally stored medications area to be locked and inaccessible to residents.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 2 resident and 2 staff files and conducted interviews during this visit.