Facility Evaluation Report

At 11:00AM on 09/19/2025 Licensing Program Analyst (LPA) De Leon arrived at the facility unannounced for annual inspection visit and met with staff whom contacted Administrator. Administrator arrived at the facility and LPA met with Administrator, Debbie Starling and explained the purpose of the visit.

The facility is a 8 bedroom, 3 bathroom facility. All bedrooms are capable of double client occupancy. This is a Tri-Counties vendor facility. The facility maintains conformity with State Fire Marshall regulations. The facility does not have any bodies of water on the premises. All outdoor and indoor passageways are free of obstruction. Disinfectants, cleaning solutions are stored in the locked laundry room inaccessible to clients in care. Lamps and lights are present in all rooms to ensure the comfort and safety of all clients. Hot water temperature is maintained within regulation. All toilets, hand washing, and bathing facilities are clean, safe and sanitary, and in operating condition with liquid soap and paper towels. The licensee ensures that each client has clean linen in good repair, including blankets, bedspreads, top and bottom sheets, pillow cases and mattress pads, and bath towels, hand towels and washcloths. Facility has one functioning carbon monoxide detector and functioning smoke detectors in all client rooms and common area living room. All food is selected, stored, prepared, and served in a safe and healthful manner with at least 2 days off non-perishable and 7 days of perishable foods on hand at this facility. All foods are protected against contamination. The licensee provides those services identified in the clients needs and services plan as necessary to meet the clients needs. Medication is kept in a safe and locked medication cart in the office which is not accessible to persons other than employees responsible for the supervision of centrally stored medication. LPA observed all required postings in the facility.

LPA conducted an audit of all centrally stored medications. LPA reviewed 5 staff and 5 client files. Administrator and LPA conducted a full review of the annual care tools and had no citations or violations issued. LPA conducted two staff interviews and all clients were at day programs.

Exit interview conducted and copy of report printed for Administrator.