Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Care Programs Manager (CPM) Christina Paad.

The facility has a licensed capacity of 22 clients, 4 of which may be non-ambulatory. During today’s visit, the facility had a census of 11 clients. The Administrator for the facility is Tonya Danielly. During today’s visit, LPA inspected each room of the facility, including activity rooms, common bathrooms, kitchen, and outside space. No bodies of water, delayed egress, or secured perimeter were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. LPA observed linens and hygiene products for client use. The facility’s ambient was measured within regulatory requirements. LPA observed that bathrooms for client use did not have any water coming from the hot water tap and CPM confirmed the bathrooms did not have hot water. CPM showed LPA two sinks which did have hot water, which LPA measured within regulatory requirements. LPA observed locked storage for client medications and hazardous and/or toxic chemicals, both of which were stored separately from food supplies. According to Christina Paad, no firearms or weapons are stored on the premises. LPA observed an adequate food supply to ensure attending clients were able to have meals as necessary. The refrigerator and freezer temperatures were kept within requirements. Staff present at the facility had a criminal background clearance and association.