Facility Evaluation Report

Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA rang the door bell and called the facility phone and no response. LPA called License and informed Licensee of my arrival. Licensee stated she would call her staff and call me back. LPA was greeted and granted entry into the facility by DSP staff, LaTanya Williams. LPA introduced self and stated purpose of the visit. LPA was informed that the current census is three (3), and all 3 clients are on their way to program.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining area, living room, family room, office area, backyard, and attached garage. LPA completed a walk through of facility, review of records, P&I and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed that two (2) out of four (4) client's bedroom light switch is not functioning. A Deficiency issued. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. LPA observed that the facility has a supply of hygiene products for the clients. Water temperatures tested at 115.3, 124, and 126,9 degrees Fahrenheit. The water temperature measured above regulation levels. A Deficiency issued. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, first aid kit, emergency kits and emergency food and water. Posters such as; the personal rights, disaster plans, CCL complaint poster, and license were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients. There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. There is no swimming pool, bodies of water, firearms or ammunition in the facility. LPA observed the kitchen cabinet and drawer were loose and not attached properly. A Deficiency issued.