Facility Evaluation Report

04/29/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 3 clients in care. LPA met with Co-Administrator, Judy Johnson. Administrator, Grace Toliver arrived shortly after and was present for inspection but had to leave for another pre-planned appointment and Judy Johnson was to sign report on her behalf.

LPA conducted a review of 3 client records. All records had the required documentation. LPA conducted review of 4 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.

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 furnished per regulation. All rooms were in good repair. Water temperature in sinks accessible to clients in care were measured and were found to be within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 03/2025. 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 were located in the hallway closet and found to be secured. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Clients handle their own cash. Facilities last fire/disaster drill was conducted 01/2025.