Facility Evaluation Report

On May, 19, 2024, at 1:30 pm, Licensing Program Analyst (LPA) Kayla Adkison, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Regional Director, Carrie Lustig, and explained the purpose of the visit. All clients and additional staff were on a field trip at the time of inspection.

LPA and Regional Director toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, and common restrooms. LPA observed the facility to be clean, in good repair, and odor-free. LPA observed the bedrooms to be clean and have all the required furnishing and lighting. LPA observed medications to be locked and inaccessible to residents. LPA observed chemical toxins to be locked and inaccessible to residents. LPA observed a variety of supplies for activities including games, puzzles, and arts and crafts.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. Sharps are kept in locked in the med room. Hot water temperature was measured within the required range. Fire extinguishers were last serviced in November, 2024. LPA observed the first aid kit to be complete and ready for use. Facility is conducting emergency disaster drills monthly. The last drill was conducted in May, 2025

LPA reviewed a total of one (1) resident files and four (4) staff files which contained all of the required documentation.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of this report was provided to Regional Director, Carrie Lustig