Facility Evaluation Report

On 04/12/22 at 9:00 am, Licensing Program Analysts (LPAs) T. White and LPAs Campbell arrived unannounced to conduct a required 1-year Annual inspection. LPAs met with Administrator, Moses Walters and Tanneh Koayen. LPAs explained the purpose of today’s inspection. LPAs was allowed entry into the facility that is licensed to serve a total capacity of 6 ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on May 11, 2021. LPAs observed completed mitigation plan on file. First aid kit observed to be complete. Fire drill was last conducted on 03/27/2022. LPAs reviewed three (3) client files and three (3) staff record files.

LPAs observed the following deficiencies:

- Based on documentation, facility is licensed to serve 6 ambulatory clients. LPAs observed Client #3 (C3) using a walker throughout the facility.