Facility Evaluation Report

Licensing Program Analyst (LPA) David Roman conducted an unannounced case management visit to follow up on the physical plant concerns from the DDS department. LPA D. Roman identified himself and was granted entry by Zack McCormick, Assistant Program Administrator. LPA D. Roman stated the purpose of the visit and reviewed the basic elements of the visit with Assistant Program Administrator, Zack McCormick.

During today’s visit, LPA D. Roman along with facility staff conducted a tour of the interior and exterior of the facility, tested the rear egress gate, and observed the facility to be fully staffed, clean and clear of hazards. In regards to the DDS department concerns: the facility is planning to redecorate the interior area of the facility with SDRC and maintenance to provide a home like feeling to the facility, however the residents DX and BX’s may increase causing property damage. The facility repaired the rear egress gate on 12/26/25. The egress gate sounds on in the office when opened without a code. The sensory room area was observed to have sensory items that can be used by residents to decrease or redirect BXs. The facility living room was rearranged to provide more of a home like feeling instead of an institution. The facility is updating its training logs/training binders to reflect the hours completed for staff. The facility is working with Home Helpers to increase staffing, 2 staff have been added to AM shifts, background checks are processing for additional staff, physical checks are also pending. Staff has been hired since October of 2025, however, continue to be pending as training requirements and background checks have to be completed.

An exit interview was conducted with Assistant Program Administrator, Zack McCormick and a copy of this report, along with the Licensee/Appeal Rights were provided at the conclusion of the visit. The signature below confirms the documents were received.