Facility Evaluation Report

04/23/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. There are currently two clients in care. LPA was greeted by staff member who informed LPA that Administrator, Judy Johnson was currently at a doctors appointment with a client. One client was present during inspection. Administrator, Judy Johnson arrived at approximately 11:00AM.

LPA and staff 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. Facility has emergency water supplies. All rooms were furnished and in good repair. Extra hygiene products and linens were available . Water temperature in sinks accessible to clients in care were measured and found to be within the range of 105 to 120 degrees F. Fire extinguishers were last inspected February 2026. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Chemicals and sharps were located in the pantry room and were found to be inaccessible to clients. Medications were found to be centrally stored. LPA conducted spot medication count and found some medication to not be on the centrally stored log. Per conversation with Administrator, client (C1) receives their medication in a roll monthly and C1s pharmacy fills out the centrally stored log and delivers it to the facility along with the medication. Administrator stated they will contact the pharmacy to ensure all the medication C1 receives from the pharmacy is correctly reflected on the centrally stored log. (Technical Advisory)

LPA conducted a review of two client records. LPA found C1 to not have an admission agreement (Technical Violation) . Clients handle their own cash. LPA conducted review of two staff records/training. Upon a review of staff records, LPA found all staff to have required training as well as current 1st Aid & CPR certification on file. Facilities last emergency/fire drill was conducted on 01/21/2026.