Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Ruiz 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 Licensee Dian Orr.

The facility is licensed for a maximum capacity of 4 non-ambulatory clients. During today’s visit, the facility had a census of 4 ambulatory clients, 3 of which were out in the community. The Administrator for the facility is Dian Orr and their certificate was pending.

During today’s visit, LPA toured the facility and inspected each room of the facility, including client rooms, bathrooms for client and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA 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 130.9 degrees Fahrenheit in the kitchen sink and 129.2 degrees Fahrenheit in a common bathroom. The Licensee turned down the water heater during the visit. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Dian Orr, no firearms or weapons are stored on the premises. LPA also observed locked storage for client medications and client and staff files. Client medications are stored in their original container and labelled. LPA 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 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate.