Facility Evaluation Report

03/11/2025 at approximately 9:40 AM , Licensing Program Analysis (LPA) Stevenson conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by DSP-Caregiver Marcel Love who called Administrator Dante Ward who arrived at approximately 10:15AM. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 4 clients in care. Upon arrival, 4 clients were in the facility with one client awaiting transport to day programming.

At approximately 10:40 AM , LPA and administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner.

All rooms were equipped with lighting, night stand, and chest of drawers. The toilet near bedroom #1 was observed to have a cracked and leaking toilet with the wrong size toilet seat and cover (pictures taken)(technical violation issued)

Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured to be at 117 degrees and within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 02/2025 and found to be fully charged. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients to be secured. P & I monies were documented and found to not be co-mingled. Facility conducts quarterly fire and disaster drills.

LPAs conducted a review of 4 client records. Record review, observation and interview with administrator determined that one (1) of four (4) client records did not contain physicians assessment LIC602 and TB clearance, which poses/posed a potential health, safety or personal rights risk to persons in care . (type B deficiency cited)

LPA conducted review of 5 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.