Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a required annual inspection utilizing the inspection tool. LPA met with Behavioral Consultant and explained the purpose of the visit.

Today's inspection, LPA and Behavioral Consultant conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: clients bedrooms, bathroom, kitchen, laundry room, medication room, backyard, and the common areas. LPA observed client rooms to have the required furnishings and fixtures. LPA observed facility to have several activities available for clients in care. LPA observed facility to be at a comfortable temperature for clients in care. LPA observed fire extinguishers present with service date of April 16, 2025. LPA observed sharps to be locked in the kitchen. LPA observed toxins to be locked under the sink. LPA observed medication room to be locked, once inside, LPA observed the medication cart to additionally be locked. LPA observed the present of six direct service providers (DSPs) working at the facility with four clients present. LPA observed facility to have ample supply of perishable and nonperishable foods for the clients. LPA observed facility to have temperature log documentation of the refrigerator to ensure it is in working condition. LPA observed kitchen to be free of litter and rodents and/or vermin. In areas toured, no immediate health, safety or personal rights violation was observed.

File review was conducted for four clients records and four personnel records. LPA observed the required documents present in the clients records. LPA observed personnel records to have proper training along with first aid and CPR certificate.

CARE tool was completed and no deficiencies cited.

Exit interview conducted and a copy of report was provided.