Facility Evaluation Report

On 02/27/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross made an unannounced visit to the facility to conduct an annual inspection. LPA was greeted and granted entry by Program Director Healthcliffe Moore, where LPA explained the purpose of the visit. The facility has a fire clearance for 25 ambulatory and 25 non-ambulatory adult clients and is approved for delayed egress. At the time of the visit there were twelve (12) staff and six (6) clients present. All staff were observed to have obtained criminal record clearance and to be associated to the facility.

LPA conducted a tour of the interior and exterior of the facility. The facility was observed to be clean, and clutter free. The facility is a single level suite with staff office's, three (3) restrooms, an art room, computer lab, sensory room, Multipurpose room, kitchen and a garden, which contains shaded areas to sit as well as playground equipment. LPA observed several activities and games to promote socialization and physical fitness, including exercise equipment, a swing and a variety of board games/puzzles.

LPA made observations throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. The facility is conducting emergency disaster drills every six months as required. Last drills were conducted on 11/06/2025. The annual fire inspection was last completed on 07/21/2025. The carbon monoxide and smoke detectors were observed to be operable. The facility has two (2) fire extinguishers that were last fully inspected on 02/04/2026. Hot water temperature tested at 108.9 which is within required temperature range. The cleaning solutions and disinfectants were observed in a locked supply closet and were in accessible to clients. The medications are inaccessible also observed to be stored in a locked medication cart.