Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived announced to conduct the facility's pre-licensing inspection. LPA met with Administrator Derek Cisna, Program Director James Blumenschein, Compliance Operations Manager Danielle Morgan, Compliance Laura Hagan.

The facility's fire clearance is approved for 8 ambulatory clients. There are no clients on-site.

During visit, LPA toured the facility with Danielle to include the entry, office, group room, bathrooms, client bedrooms, backyard, kitchen, garage, and living room. All exit routes are free and clear of obstruction. The facility has operable carbon monoxide detectors / smoke alarms throughout the building. Fire extinguishers serviced on 05/16/2023. First Aid Kits observed throughout the facility.

Facility's entrance contains a sign-in sheet, schedule, house rules, medication time, visitor policy, licensing complaint poster, personal rights, resident counsel, and COVID-19 related poster.

Office room observed secured with locks on the doors. The office room contains an operable telephone, locked medication cabinet, locked medication refrigerator, sharps bin, complete first aid kit, evacuation map, flight lights, and the emergency disaster plans. LPA observed the facility has a Personal Protective Equipment (PPE) cart to include supplies such as gowns, gloves, masks, shields and hand sanitizer.

4 out of 4 bedrooms contain adequate lighting, beds, clean linens, night stands, lamp shades, dressers and closet space.