Facility Evaluation Report

At 7:30am on 03/17/2025, Licensing Program Analysts (LPA) Haner-Tomasko and Jeffries, arrived unannounced at the facility to conduct the annual facility inspection. LPAs met with Primary Staff Trey Correy (S1), announced who they are, and the reason for the visit.

S1 and LPA conducted a full tour of the facility. The facility is a 3-bedroom 2.5-bathroom house, with a living room, kitchen, and dining area. There are two client bedrooms that are dual occupancy and one primary bedroom for the live-in staff. The clients share a full and half bathroom. The other full bathroom is attached to the primary bedroom. LPA noted that the bathrooms are clean and functioning. Hand soap and paper towels available in each one. LPA tested and noted the facility water temperature to be 116.5*(f), within regulation range of 105*-120* (f). LPA observed a first aid kit in the laundry room. The laundry room is locked and that is where the chemicals and medication are kept. There is a patio with shade pergola and umbrella in the back yard for client to use. LPA noted a fire extinguisher fully charged and inspected January 2025. LPA noted smoke alarms located in each room throughout the facility and carbon monoxide detector in the hallway. LPA observed at least two days of perishable foods and more than seven days of non-perishable foods on hand at this facility. LPA noted that the facility telephone was operational.

LPA noted that the facility was new, clean and in good repair. LPA noted that all doors and exits were free of obstructions. LPA reviewed centrally stored medications, staff files and client files. LPA noted one client admission agreement to be incomplete. Infection control and emergency/disaster plans reviewed.

S1 and LPA conducted a review of the annual control tools modules.

Exit interview conducted, deficiencies cited, copy of report and appeal rights provided.