Facility Evaluation Report

Unannounced Annual visit made out to this facility on 05/16/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility house manager, Shontell Upton, at this time. A brief interview was conducted with the facility house manager at this time.

This LPA also met the facility designated Administrator, Angela Kirtman Harris, who was interviewed at this time.

It was learned that this facility was vendorized to be able to accept and retain up to (6) Level 4I residents at any given time.

This facility is licensed to serve up to (6) Ambulatory only residents at any given time. Current census was 6 residents, of which (5) of them, were out of the facility at their respectable day programs at this time.

A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.

Cleaning agents, bleach, and other supplies which were stored in a closet underneath the stairwell were observed to be locked and made inaccessible to the residents at this time.

A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.

Medication cabinet, located in the facility living room entertainment stand, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated staff member at this time. A review of the facility Medication Administration Record and dispensing log was conducted.