Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required Inspection and met with Administrator Madison Johnson-Reed.

LPA/Administrator initiated a tour of the facility at 9:00 am. Passageways were free of obstruction. Water temperature measured at 115.4 and 112.1 degrees F. One carbon monoxide detector in the hallway was tested and properly working. Two fire extinguishers were charged and serviced May 2024. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to clients. Linens, blankets, and bedspreads were observed on all beds. Non-perishable and perishable food supply met the minimum requirements. Refrigerator was clean and food stored properly. Medications are locked in a cabinet in the activity area. Facility's fire sprinkler alarm system is linked to a vendor May 20, 2024. Emergency Disaster drill was conducted on July 10, 2024. Cash resources and records were reviewed. Annual fees are current and contact information was reviewed.

LPA initiated file review at 9:25am. Four of four client files and three staff files. Staff records have current First Aid/CPR certificates. Medications and medication records were reviewed. Administrator Certificate for Madison Johnson-Reed 6066146735, expires on 2/26/2025. PRN waiver was reviewed.

Administrator to submit updates of the following documents by 8/1/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Administrative Organization (LIC309), cash affidavit for clients (LIC400), surety bond, lease agreement, and Emergency Disaster Plan (LIC610E). No deficiencies were cited during this inspection. Exit interview was conducted with Administrator and a copy of this report was given.