Facility Evaluation Report

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Dan Doran. LPA stated the purpose of the visit. LPA observed 37 clients and 13 staff.

LPA toured the interior and exterior of the facility with ADM to include the kitchen, bathrooms, activity area and garden area. LPA observed clients engaged in art activities with staff, and clients gardening with staff. All exit and passageways were free and clear of obstruction.

LPA toured the kitchen area and observed cleaning products locked in a cabinet.

LPA observed the medication storage area as locked and inaccessible to clients in care.

The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 2/5/2025. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was in June 2025.

LPA toured 2 bathrooms. All 2 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature with a range of 107.5 degrees F to 108.8 degrees F.