Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA met with Administrator Evelyn Green . At the time of the visit, two(2) clients were present at the facility.

LPA toured the facility inside and outside. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 4/16/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the laundry areas. Centrally stored medications were kept in a safe and locked cabinet. LPA measured the hot water temperature in the bathrooms and kitchen. The hot water temperature in the client bathroom was within required limits. LPA observed emergency supplies in the garage. The outside of the facility had a shaded area with a table and chairs. The facility does not have a pool or bodies of water.

LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. LPA observed the signs and postings in a common area. LPA observed the Emergency Disaster Plan was not updated as of 2021. LPA did not see the visitation policy posted. Deficiencies were issued. Sufficient staff are employed and present in the facility to meet the needs of the clients in care.

Two (2) deficiencies were issued during this visit. An exit interview was conducted where this report, LIC 809, LIC809-D and appeal rights was provided to the Administrator Evelyn Green, at the end of the visit.