Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo and Contreras arrived unannounced to conduct a required Annual inspection and was greeted by Administrator (Admin) Simika Simmons.

At approximately 10:30am LPA toured the building and grounds. Upon arrival, LPAs rang the doorbell but did not see any staff present. Admin explained that her boss, Julie Schuder, COO will be installing a new doorbell next week in order to address the doorbell not ringing in the front area.

The facility was found to be clean and at a comfortable temperature. Lunch is not provided; participants typically bring their lunch or go out lunch. Kitchen is equipped with refrigerator, freezer, microwave, and oven. Staffing ratios are either 1 to 1 or 1 to 3. LPA observed six [6] participants present in facility supervised by two 2 staff. Admin advised that they staff according to client attendance but that typically they have at least 10 staff on shift. Often, staff take participants to lunch and on outing like to the dollar store.

Water temperature in sink accessible to participants in care measured at 134.7 degrees F which is not within the allowable range of 105 to 120 degrees F. Admin explained that the facility has their own maintenance person, they do not utilize the landlord's maintenance. LPA and Admin discussed water temperature is too high and outside of regulation ( deficiency cited, see 809D ).

Fire extinguishers were last inspected 10/10/24. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted on 4/3/25. Fire