Facility Evaluation Report

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct an inspection to follow up on areas of concern that were observed during a Department of Developmental Services (DDS) onsite visit on 12/18/2025. LPA met with Co-Administrator Kaylee Dodd.

There were 3 areas of concern in the report: Sharps in a drawer, sufficient staffing and CPR. LPA found that sharps (a small bag of screws) had been removed from drawer and staff were reminded of the directive that clients should not have access to sharps. An inspection of the facility found that staff were thorough in the removal of all sharps and none were found to be accessible to clients. All sharps are locked in metal cabinets by staff room.

Administrator Fleming was contacted regarding the staffing concerns and stated that they received clarification on the promotion of leads and now have leads for each shift. LPA reviewed staffing schedules and found a lead for each shift, including NOC shifts for the month of January. Lastly, the facility now has a tracker that has due dates for First Aid/CPR and other trainings and the one staff person who was missing the training is now in good standing. *Note In-service First Aid/CPR training was being conducted at the facility at the time of visit.

LPA Nakagawa reviewed the areas of concern addressed in the Department of Developmental Services (DDS) onsite report dated 12/18/2025 and found they were observed to be in compliance with Title 22 Regulations.

No deficiencies were found at the time of inspection. No citations issued.