Facility Evaluation Report

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility by Staff, Ray Burgos and Staff, Joy Bonner. Administrator, Holly Goolsby arrived during the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, all of whom must be ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. 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 internal temperature was 71 F. Hot water temperature at taps accessible to clients measured at 110 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, not safely stored. LPA observed an open zip lock bag in the freezer with uncooked chicken, the skin on the chicken was brown. There was another frozen pack of chicken that was uncovered with frost bite, along with another opened bag of meat, not stored properly. There was a pack of frozen ground beef cut in half and stored in the freezer uncovered. Staff disposed of food items not stored properly. The food that were not stored appropriately, were being prepared and served to the clients. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Continued on LIC 809C.