Facility Evaluation Report

Licensing Program Analyst (LPA) Sommer Hayes arrived unannounced to conduct a Required - 1 Year visit on 06/13/25 at 8:40am. LPA met with Beatrice Clark, Designated Administrator and stated the purpose of today’s visit.

The facility is licensed for a capacity of 6 non-ambulatory residents. The current census is 5. LPA toured with the DFA 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. LPA Hayes observed one (1) pair of scissors with a grey handle in an unlocked kitchen drawer.

The temperature inside the facility was observed to be at 72 degrees F which is within the required range of 68-85 F. The hot water temperature was measured at 117 F which is within the required range of 105-120*F. LPA observed a fire extinguisher, smoke and carbon monoxide detectors, and central heating and air in the facility.

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 reviewed 2 resident records; staff records were not available for review. The garage is not accessible to clients. There was an outdoor refrigerator, non-perishables and emergency food supply.

LPA observed the backyard of the facility. There was a shaded area for residents to enjoy. Fencing was in good repair. There were no bodies of water.