Facility Evaluation Report

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA met with staff and later with Administrator Lyndon Ganir and explained the reason for the visit. Census:3

LPA Lund toured/inspected the facility inside and outside. Pathways were observed to be free of obstruction and fire hazards. The facility's fire clearance was approved for 4 ambulatory clients two (2) of which may be non-ambulatory in Rooms #1 & 2 only. Lan line phone. Centrally stored medications were locked in a cabinet underneath the kitchen counter. Sharp objects were locked in the kitchen cabinet next to the stove. Toxic chemicals were locked inside the garage. LPA observed there was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 73 degrees Fahrenheit. Client's bathrooms have paper towels, grab bars and a non-skid tiled floor. Last Fire drill was conducted on 8/25/23 which staff/clients practice every three (3) months. Fire extinguisher was fully charged and last inspected on 8/19/23. Dual Smoke & Carbon monoxide detectors were operational.

LPA reviewed two (2) clients and two (2) staff files. Staff had criminal record clearances to work and are associated to the facility. Clients records all contain SFRC Admission Agreements, medical assessments, needs and service plans/appraisals, Consent forms, SFRC Individual Service Plans (ISPs) and Individual Program Plans (IPPs), Behaviorist reports. The facility has potentially dangerous objects locked and inaccessible to clients in care. P&I monies were reviewed and observed to match records as well as kept secure/intact from other facility funds.

No deficiencies were observed in the areas that were evaluated. No citations were issued during today’s inspection.

Exit interview conducted with Administrator Lyndon Ganir and a copy of this report provided.