Facility Evaluation Report

08/19/2025, Licensing Program Analysts (LPA) Hansen conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility is an enhanced behavioral. Facility is a single story with 4 bedrooms. There are currently four(4) clients in care. Facility approved for four(4) non-ambulatory. LPA met with the Licensee Michael Mwichigi as Administrator was unavailable.

At approximately 10:40 am, LPA and Licensee 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 being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. LPA observed a clients room with broken/missing blinds and approximately 16 holes client has made in walls throughout the facility (see pics & LIC809-D). Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 112.8 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected July 17, 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 in care were found to be locked and secured in a cabinet located in the kitchen; although there were multiple cans of paint on floor of garage and Clorox wipes on counter of laundry room, accessible to clients in care (see pics & LIC 809-D).

At approximately 12:30 pm, LPA conducted a review of four(4) client records. All records had the required documentation. P&I monies were documented, secure and not commingled.