Facility Evaluation Report

On 12/02/2025 at 8:00am, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the facility annual inspection. LPA met with Administrator, Estela Usher, announced who he is and the reason for the visit and was later joined by DSP Juliet Danderson.

This facility is 4 bedroom, 2 bathroom, Kitchen, Dinning room, 2 Living rooms, Staff office, and a pergola in the back yard patio with tables and umbrella for client activities and visitation. All client rooms are single occupancy. LPA toured the full facility and noted that all client bedrooms have proper and sufficient amounts of linin. All clients have chair, table, lighting and storage per regulations. Facility bathrooms are properly equipped with liquid soap and paper towels and electric hand dryer. LPA noted that there are two days of perishable foods and at least seven days of non-perishable foods on hand for four clients and staff. LPA noted that there are smoke detectors throughout the facility that were tested and functioning, LPA noted that the carbon monoxide detector was tested and functioning. LPA noted that the fire extinguisher located in the dining room was tagged as serviced and indicating in the green as primed. LPA noted that the First Aide kit is located in the staff office, as well as the medications and staff and client records all secured in lockable cabinets. LPA noted that the all posting are located in the staff office. LPA noted that the facility is clean and in good repair. LPA noted that they did not find any violations during the physical tour of the facility and no citations were issued.

LPA conducted file review of staff and client files including Centrally Stored Medication Records (CSMR). LPA noted documentation to be complete. LPA and Administrator conducted a full review of annual care tools and noted that no citations were issued as a result of the annual care tools review. And no citations issued as a result of CSMR, client and staff files review. At this time there were no violations or citations issued as a result of the facilities annual inspection

Exit interview, report read, and report provided