Facility Evaluation Report

On October 7, 2025, at 01:00 PM Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Angel Doss and explained the purpose of the visit. Administrator certificate is current (10/26/2026). During the inspection, (4) four staff were present. All (5) five clients were all in day program and returned during the inspection.

LPA Adkison and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to five (5) resident rooms, common areas, three (3) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. (4) four staff and (5) five resident files were reviewed and contained all required documentation. Medications were also reviewed and found to be in compliance. Medication is kept locked in a cabinet and is inaccessible to clients in care.

The areas observed were found to be clean and in good repair. Cooking/dining equipment and utensils were present. All sharps and cleaning supplies were observed to be locked and inaccessible to clients to care. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Clients personal dietary needs are posted for staff to review. LPA observed a variety of games and art supplies for client use. Staff was in the process of updating the facility's calendar of events for the month.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged and last inspected in July 2025. Smoke detectors are all operational. All employees requiring background checks are cleared.. All required postings are displayed within the facility. The last disaster drill was conducted and documented in September 2025. The facility has been conducting and documenting drills every 3 months.

The facility is in compliance. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to administrator, Angel Doss, via email