Facility Evaluation Report

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

LPA and co-Administrator conducted a tour of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: residents bedrooms, bathrooms, kitchen and the common areas. LPA observed fire extinguishers present throughout the facility, recently serviced November 15, 2024. LPA observed residents in care to be eating and supervised by direct support professional. LPA observed residents rooms to be clean and sanitary. LPA observed sharps, toxins and medications to be locked and secured. LPA observed facility to have adequate activities available for residents in care. In areas toured, no immediate health, safety, personal rights violations were observed.

File review was conducted for residents and personnel records. Additionally, LPA conducted file review of facility fire drills records. LPA and Administrator discussed updating the Emergency Disaster Plan to the updated nine page form. A copy was provided.

At this time, LPA is requesting a copy of facility liability insurance to be emailed to LPA.

CARE tool was completed with Administrator and found facility to be compliance. No deficiencies cited.

Exit interview was conducted with Administrator. A copy was provided.