Facility Evaluation Report

At 7:45am on 03/06/2025, Licensing Program Analysts (LAP) Haner-Tomasko and Jeffries arrived unannounced at the facility to conduct the annual, facility inspection. LPAs met with Licensee and explained the reason for the visit being the full annual inspection.

Licensee and LPAs conducted a full tour of the facility. LPAs noted that the facility is a six bedroom, two and a half bathrooms, with one room being double client occupancy, four rooms are single client occupancy, and a full-time staff occupies the sixth bedroom. The full-time staff has a full bathroom in the master bedroom and the clients share the upstairs full bathroom and the downstairs half bathroom, LPAs noted that carbon monoxide detectors and smoke detectors are located throughout the facility and the carbon monoxide detector in the kitchen was tested and in good working order. LPAs observed at least two-day supply of perishable and at least seven-day supply of non-perishable foods on hand at the facility. LPAs observed liquid soap and paper towels in the bathrooms. LPAs observed at least a 30-day supply of PPE on hand at the facility. LPAs noted that the medication cart is locked in the office downstairs. A sample medication audit was conducted. LPAs noted that water temperature was 114.5*(f) and is within regulation parameters of 105*-120*(f). LPAs noted that the facility is very clean. No exits were obstructed. LPAs reviewed the facility infection control plan and disaster plan.

Administrator and LPAs conducted the full annual review of control modules. No violations or citations were issued.

Exit interview, report read, report signed, and report delivered.