Facility Evaluation Report

Licensing Program Analyst (LPA) Olson arrived at the facility unannounced to conduct a required annual visit at 10:45 a.m. LPA met with Administrator and Executive Director (over the phone) and explained the reason for the visit. The program currently operates from 8:00 a.m. to 4:00 p.m.

Common Activity Space : The facility is a single-story structure with a conference room, offices, relaxing/multipurpose room, bead room, three (3) bathrooms, and a large open program area. LPA did not observe any obstructions or hazards. Furniture and equipment was observed to be in good condition. Carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed fire extinguishers throughout the facility, which were last serviced 01/10/2023.

Activities: Activities are both designed for individual and as a group. Some consumers do day outings.

Food Service : Consumers bring their lunch and snacks. The facility has emergency food supplies and snacks available for consumers.

Restrooms : Restrooms were clean and sanitary and stocked with soap and paper towels. At 12:19 p.m., water temperature in the restroom was measured at 110.9 degrees Fahrenheit. The hot water measured was within the required limit of 105-120 degrees Fahrenheit.

Record Review : Around 12:30 p.m. a review of facility files was initiated. LPA obtained Client Roster and Staff Roster. LPA reviewed five (5) of (81) Client Files. LPA reviewed three (3) of (55) staff files. All staff files were complete.

Medications: Medications are centrally stored and locked in a cabinet in an office. Medications are labeled and checked for expiration dates. Medications could use better documentation on the centrally stored medications and destruction record.