Facility Evaluation Report

On December 06, 2024, at 1:45 PM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the CEO, Maria Nicolacoudis and disclosed the purpose of the inspection.

LPA toured the physical plant and observed it to be clean and odor-free at a comfortable temperature and adequate lighting. LPA inspected 3 activities rooms in the main building – Diamond room, Emerald room, and Ruby room. Clients were observed engaged in activities, playing dart, bingo games, and craft activities, and exercising. LPA inspected the new section/building added recently for higher functioning clients and observed clients participating in Christmas Carol Bingo in Craft café room. LPA inspected Program Rooms #1 and #2, technical center, and the laundry room. No obstructions were observed in the hallways.

LPA inspected outdoor patio area next to Emerald room, and observed outdoor table, chairs, and umbrellas for clients’ use and garden beds for gardening activities. No accessible bodies of water or fire safety/tripping hazards were observed.

LPA inspected the kitchen and observed sharp objects and cleaning supplies were stored/locked properly and inaccessible to the clients. No cooking was observed. The CEO mentioned that staff prepares snacks for the clients and lunch is catered through IL Pastaio Food and is served once it is brought. LPA inspected the refrigerator and observed milk, cheese, fresh vegetables, and fruits stored.

The bathrooms were observed to be clean and equipped with trash cans, grab bars, liquid soap, and paper towels. The hot water temperature was measured in (2) bathrooms at 109.4°F and 108.7°F.

The client’s medications were securely stored in a locked Med room. Medications were organized in separate bins for each client. All medication bottles were properly labeled. Centrally Stored Medication Records (CSMR) and Medication Administration Record (MAR) were reviewed and found to be complete. LPA inspected the first aid kit and observed it fully stocked.