Facility Evaluation Report

On September 2, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Grace Donato arrived at the facility at 08:50 AM to conduct the Annual 1-year required inspection. LPAs met with the Angie Jacob, Case Manager and Adam Canon, Behavioral Aide, and explained the purpose of the visit. LPAs were later joined by the Program Director Ryan Mock.

LPAs toured the physical plant. LPAs observed 5 rooms – store front, quite room, exercise room, art room, game/movie room, main common room to be clean and well-maintained. No accessible bodies of water or hazards were observed. Fire extinguishers were fully charged and last serviced on August 2024. Smoke detectors and carbon monoxide detectors were observed to be in working condition. Adequate lighting and comfortable indoor temperature were observed in the facility. Emergency exit routes are marked, and an emergency evacuation plan was posted in each room.

LPAs observed toxins, cleaning supplies, and sharp objects locked away in the storage/chemicals room and were inaccessible to the participants. No cooking or meal preparation was seen at the facility. Participants bring their own lunch/food, which they could warm in the microwave with the help of staff members. Kitchen use is primarily for staff members. The Refrigerator in the kitchen is used to store staff food. LPAs observed bathroom areas to be fully stocked with paper towels, hand soap, and a trash can. The bathroom faucet water temperature was measured at 112.8 °F.

Participants were observed sitting in the main common area, engaging in activities, exercising, and assisting with daily chores. LPAs reviewed 5 random participant files and 5 random staff files. All were observed to be complete. The client’s medications were securely stored in a locked cabinet. The First Aid kit was checked and found to have the required items. Emergency drills are conducted quarterly with the last drill documented on May, 2024.

No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Angie Jacob and Ryan Mock and a copy of this report was left at the facility.