Facility Evaluation Report

On November 21, 2025, Licensing Program Analyst (LPA) Kayla Adkison, arrived at the facility unannounced to conduct the Required Annual Inspection. LPA was greeted by Lenah Bradley, DIrect Care Staff (DSP), and explained the purpose of the visit. Administrator, Brenda Bigler, arrived approximately 10 minutes later and joined the inspection. Administrator certificate was posted and expires in March 2026. During the inspection, two (2) staff and one (1) resident were present. All other clients were participating in off-site day programs.

LPA, DSP, and Administrator toured the facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, kitchen, backyard, and (2) two restrooms. LPA observed all walkways, hallways, and ramps to be free of clutter and obstructions. LPA observed each bedroom to have the required furnishings and working lights. LPA observed one (1) client bedroom to have a broken window and a large hole in the door. Administrator stated the damages occurred this week and are already scheduled to be replaced. LPA observed the facility to be at a comfortable temperature. Hot water temperature measured between 105 F and 120 F and was compliant with Title 22 regulations.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. LPA observed all medications, and sharps to be kept locked away and inaccessible to clients in care. LPA reviewed Medication Administration Records (MARs) and found them to be current and accurate. There were various activities available for client recreation, including craft and cooking supplies. Administrator noted clients in care particularly enjoy participating in learning cooking skills. Administrator stated clients will be participating in an upcoming overnight to trip to the beach and the Polar Express train ride.

Fire extinguishers, smoke detectors, and carbon monoxide detectors were observed and found to be in working condition. The facility is conducting emergency disaster drills monthly with the last drill being documented in November 2025. LPA observed a complete first aid kit ready for use.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of four (4) residents' files and four (4) staff files which contained all the required documentation. All staff are fingerprint cleared and associated to the facility.

No deficiencies are being cited as a result of this inspection. Exit interview conducted. A copy of this report and was provided, via email, to Administrator Brenda Bigler, via email.