Facility Evaluation Report

At approximately 11:45AM Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct an Annual Required 1 Year inspection and met with Administrator, Jean Stephens. Upon arrival, LPA was informed that there were 3 Residents in care.

At approximately 12:20AM LPA toured the building and grounds which was found to be clean at a comfortable temperature and in good repair. All walkways and exits were observed to be unobstructed. Client rooms were furnished per regulation. Water temperature accessible to clients in care measured 113.2 degrees F which are within the required regulation range of 105 to 120 degrees F.

Extra hygiene products and linens were available. Cleaning supplies are locked and not accessible to clients. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of good quality and stored per regulation.

Fire extinguishers were last serviced 10/29/2024. Smoke/Carbon Monoxide detectors were operational. Most recent fire/disaster drill was conducted Marc 31, 2025

At approximately 01:05PM, LPA reviewed 3 resident records. 1 out of 3 residents (R1) did not have I.D. and Emergency Information document on file. All clients have medical assessments and care plans updated. Medication records are thorough and contained physician's orders for each resident. Medication records reviewed and medication centrally stored. P&I's are kept on a locked facility office room; facility responsible for all client’s P&I and money; facility had P&I and ledgers available during the visit.