Facility Evaluation Report

Licensing Program Analysts (LPAs) Rebecca Borunda and Janet Ngallo conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPAs were greeted by, identified themselves to, and explained the purpose of the visit with Co-Administrator Ivy Kasko.

The facility is licensed for a maximum capacity of 6 non-ambulatory clients. During today’s visit, the facility had a census of 6 clients, 1 of which was non-ambulatory. The Administrator for the facility is Katherine Dowden and their certificate was valid and current.

During today’s visit, LPAs toured the facility and inspected each room of the facility, including client and staff rooms, bathrooms for client and staff use, kitchen, garage, common areas, and outside space. The facility has a empty swimming pool located in the backyard, which was made inaccessible to clients via a fence with a locked gate. LPAs did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 117.0 and 118.2 degrees Fahrenheit in bathrooms for client use. The facility’s internal temperature was maintained within regulatory requirements. LPAs observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Ivy Kasko, no firearms or weapons are stored on the premises. LPAs also observed locked storage for client medications and client and staff files. Client medications are stored in their original container and labelled. LPAs observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 37 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit.