Facility Evaluation Report

On April 25, 2025, Licensing Program Analyst (LPA) Komal Charitra delivered a copy of amended LIC809.

On April 25, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Program Director Angel Carter and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas, staff office & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a two story facility. There are two client rooms on the first floor and four client rooms on the second floor; all of which are shared rooms with required furnishings. LPA observed two full bathrooms on the first floor and three full bathrooms on the second floor; clean, odor-free, equipped with liquid soap, paper-towels and non-skid mats. Extra linen was observed to be present. First aid kit was observed to be complete.

Communal areas, activity rooms, and dining room were observed to be clean and free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed two day perishables and seven day non-perishables. Medications, sharps, and chemicals were observed locked an inaccessible to clients in care. Washer and dryer were observed to be in good working condition.

Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of

January 2025. Emergency drills are logged and done every month. LPA reviewed 5 client records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No deficiencies are cited during the visit. LPA reviewed report with Program Director, Angel Carter and a copy is provided.