Facility Evaluation Report

On 06/16/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required inspection and a health and safety check. LPA was greeted and granted entry and by Direct Support Professional Evelyn Dallo, where LPA explained the purpose of the visit. At the time of the visit there was (2) staff) and (3) clients present. The facility is licensed to serve(4) ambulatory clients age 18 through 59. LPA conducted a tour of the interior and exterior and observed the following: The facility was observed to be clean with the passageways being free of any obstructions.

All staff present have obtained criminal record clearance and are associated to the facility. Staff were observed to have the required training, with valid CPR certification. The administrator Emma Imson was observed to not possess a valid administrator certificate, as certificate #6051610735, expired on 03/26/25. The department issued a citation on 05/23/25 therefore no citation was issued during today's date. Per Imson there were 20 CEUs remaining. Imson submitted proof of completed CEUs on 5/28/25. Client files were observed to have admission agreements, IPPs, and other necessary paperwork. The Personal and Incidental (P&I) funds were reviewed client #2 (C2) had $40.00 not in their pouch, and client #3 (C3) had 5 extra cents. The food supply was observed to meet with requirement of a 2 day supply of perishable and a 7 day supply of nonperishable food items. The hot water was tested and measured to be 119.2 degrees Fahrenheit.

The medications, chemicals and sharps were observed to be locked and inaccessible to clients in care. The combined smoke and carbon monoxide detectors were tested and found to be operable. The fire extinguishers were fully charged, with the tag in tact. The emergency disaster drills are being conducted on a quarterly basis, last drill was on 06/01/25. During today's inspection there were no health and safety concerns, or deficiencies observed. An exit interview was conducted and a copy of this report was reviewed and provided to Evelyn Dallo, Direct Support Professional.