Facility Evaluation Report

Licensing Program Analyst (LPA) Rankin arrived at 8:15 a.m. and made an unannounced 1-year required annual visit to the facility above. LPA met with staff and explained the purpose of the visit. Designee back up showed up at around 8:45 am and Estella Usher Administrator arrived at approximately 10:35 am. Annual visit is in conjunction with close out of complaint # 29-AS-20260409122534.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility is a 3 bedroom, 2 bath, occupying 3 clients. The facility has smoke and carbon monoxide detectors that were tested and working at time of visit. The toilet, hand washing and bathing facilities are operational. Facility is well lit inside and outside for safety. Water was tested at 109.3 in the kitchen and 107.6 in the master bathroom. Disinfectants and cleaning solutions are inaccessible to residents and are locked and stored in a cupboard in the garage and under the kitchen sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The fire extinguishers were last charged and inspected on 1/8/2026.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 4 ambulatory.

Staffing & Training: The facility currently employs 11 staff of which 2 are administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint Clearance/Associations/ exemptions. Administrator’s Certificate expires 1/18/27. Staff have annual training completed for various subjects/topics and hours for 2025 and 2026. Continue on 809-C