Facility Evaluation Report

On 10/21/2025 at 10:00am Licensing Program Analyst (LPA) Jeffries conducted an unannounced facility annual inspection. LPA met with facility Administrator, Ronica Smith. LPA announced who he is and the reason for the visit.

LPA noted that the original report was deleted when computer conducted an unexpected reset losing original report. The following is a summary of that report. During the physical tour the facility remained in regulation compliance with no hazards observed. LPA noted that Fire clearance regulations were followed with smoke detectors throughout the facility and carbon monoxide detector tested and functioning. All door, hallways and passage ways were free and clear of obstructions and there were 4 observed fire extinguishers throughout the facility that were all primed and in the green. Additionally the facility has a industrial sprinkler system as the main fire control device serviced by the property manager of the building complex. LPA noted and observed documentation that the facility conducts and documents fire drills in accordance with regulations. LPA tested the water in all three facility bathrooms to be in regulation parameters of 105*-120* (f). LPA noted that there are currently no clients the require medications, however medication can be locked in a cabinet in the Administrators locked office, where the completed first aide kit is located. LPA noted that all staff are receive training on passing medication if needed. LPA noted that the facility was clean and in good repair. LPA noted that a full review of annual care tools was conducted with no violations or citations issued. LPA conducted a cursory review of client and staff files and found no violations or citations. LPA noted that staff have required amount of annual training including CPR and FIrst Adie. LPA reviewed facility infection control plan and emergency disaster plan. LPA noted that this full annual inspection had no citations or violations. The original report was singed by Administrator Ronica Smith at location at the end of the inspection.