Facility Evaluation Report

Licensing Program Analyst (LPA) Correia conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by DSP Hassan, identified herself, and discussed the purpose of the visit.

According to the facility’s license, there is a maximum capacity of four (4) clients ages 18 to 59 all of whom may be bedridden. During today’s inspection all four (4) clients were present.

LPA Correia conducted a record review for Staff and Clients in care that were observed to be organized, accurate, and complete, including staff training, and active administrator certification. LPA also reviewed clients P&I ledger and cash resources, as well as Medication Administration Records (MAR) and medication orders that were also observed to be accurate and complete. The facility has active liability insurance and surety bond. The last fire drill was conducted on July 15, 2025.

LPA, accompanied by DSP Hassan, toured the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. The facility was equipped with smoke and carbon monoxide detectors, and fire extinguishers that were all operable and/or up to date.

Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient temperature was 76 degrees Fahrenheit, and hot water temperature at taps used by clients measures at 105.1.