Facility Evaluation Report

On October 3, 2024, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility at 8:45 AM to conduct the Annual 1-year required inspection. Upon arrival, LPA met with Henry Akapo, DSP and Aminata Kamara, DSP, and explained the purpose of the visit. Naward Smith, Administrator joined shortly after.

LPA toured the physical plant in the presence of the staff member Henry Akapo. The facility was observed to be clean, in good repair, and maintained at a comfortable temperature with adequate lighting. During the tour, two staff members were seen present in the facility. Two residents were away at the day programs and two at their doctors appointment. The facility sketch includes 4 bedrooms, 2½ bathrooms, a living and family room, a kitchen with dining, a garage, and 4 exit doors for access to the exterior area of the facility. No accessible bodies of water or fire safety hazards were observed.

At 9:14 AM, LPA inspected all three residents’ rooms and observed them to be clean with sufficient furniture and operational light fixtures. All rooms are shared. The two full bathrooms were observed to be clean and contained non-skid mats, grab bars, trash cans, liquid soap, and paper towels. The bathroom #1 faucet hot water temperature was measured at 108.1°F.

At 9:26 AM, LPA observed an office room which is not included in the facility sketch. According to the Administrator, one of the bedrooms has been converted into an office room for a long time.

At 9:32 AM, LPA inspected the half bathroom and observed disinfectant, bleach, and other cleaning solutions were not stored/locked properly and accessible to the residents, which poses immediate health risk to the person in care.

At 9:42 AM, LPA inspected the kitchen and observed it to be clean. Toxins, cleaning supplies, and sharp objects were stored/locked properly and inaccessible to the residents. The facility had an adequate stock of food items, including 7 days of non-perishables and 2 days of perishables, with no expired items observed.

At 9:51 AM, LPA inspected the laundry area and observed it to be clean and equipped with a washer and dryer. The hallway closet was observed to contain an additional linen supply.