Facility Evaluation Report

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Executive Director Kecia Stinnett, House Manager Scott Swisher, and Assistant Executive Director Sue Laubach. At the time of the visit there was three (3) staff and zero (0) clients present. The clients served are ambulatory adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. The outdoor area was observed to be free of hazards. Facility contains a pool with a locked fence. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Three (3) client files were reviewed and contained all required paperwork including Admissions Agreement, Updated Physician's Report, and Individual Program Plan (IPP). Client medication was locked in a cabinet located in the kitchen. LPA reviewed two (2) client medications and found all medication listed on the Medication Administration Record (MAR) were present and all required labeling and signatures was found to be in place. LPA reviewed the facility's emergency and disaster plan. Facility conducted their last disaster drill on 08/04/2024 which met the department requirements. LPA observed emergency supplies and multiple fire extinguisher located throughout the facility with an inspection date 07/03/2024. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate. No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Executive Director Stinnett.