Facility Evaluation Report

On October 7, 2025, at 10:30 AM Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator, Brianna Lee, and explained the purpose of the visit. At the time of the inspection, 29 clients and 10 staff were present in the facility. LPA observed clients to be participating in a music class and had just completed a sign language lesson.

LPA Adkison and Administrator toured the facility together to ensure the health and safety of clients in care.

Areas toured include but are not limited to: one (1) large classroom, two (2) bathrooms, kitchen, quiet/rest room and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. Five (5) staff and four (4) resident files were reviewed and found to have all the necessary documentation. Medication Administration Records (MARs) were reviewed and were found to be kept locked in a file cabinet rendering them inaccessible to clients in care.

All areas observed were found to be clean and in good repair. Cooking/dining equipment and utensils were present. All clients bring their lunches from home and staff assist with preparation if needed. The facility is offering cooking/baking classes. All sharps and cleaning supplies were observed to be kept locked and inaccessible to residents to care.

The facility was observed to be at a comfortable temperature. Fire extinguisher fully charged and last inspected in June 2025. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. The facility conducts regular water temperature checks and maintains logs of the recordings. All employees requiring background checks are cleared. There is a schedule of activities and classes planned for clients. A daily schedule is posted in the main classroom every morning and staff review the schedule personally with clients as well. The last disaster drill was conducted and documented on August 2025. The facility has been conducting drills every 3 months.

LPA requested a current LIC 500 for the facility physical file. The facility is in compliance. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of this report was provided, via email, to Administrator, Brianna Lee.