Facility Evaluation Report

Licensing Program Analysts (LPAs) Eryn Kane and Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Melissa Steffenhagen, Administrator.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, all of whom must be ambulatory. During today’s inspection, there were a total of four (4) clients in care, and per medical records, all were ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPAs, accompanied by Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 75 F. Hot water temperature at taps accessible to clients was compliant: Bathroom #1 sink was 115.7 F.

No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility.

LPAs reviewed multiple files and interviewed staff. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee also presented proof of current/active business liability insurance and surety bond.

Currently the four clients are at Tommy house while this facility is under minor construction.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Melissa Steffenhagen, Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.