Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Cassie Reed, Program Manager . Annual fees are current.

At approximate 9:00am LPA initiated file review of ten client's files and five staff files. All clients have medical assessments, two out of ten clients' care plans needs to be updated. Staff have required annual training hours and CPR/1st aid certificates updated. Required postings were observed.

LPA/Program Mgr initiated a tour of the facility around 11:30am and made the following observations: Facility was a comfortable temperature, Cleaning supplies are stored in a closet that was locked at time of inspection. Client rooms were furnished per regulation. Extra hygiene products and linens were available. Fire extinguisher was last inspected April 2025. Carbon Monoxide and some detectors located throughout the facility were tested and operational. Most recent disaster drills were conducted 10/18/25. Water temperature in client bathrooms measured at 114.6 and 112.6 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Facility does not have at least two days of perishable, but there was one week of non-perishable foods. Also, LPA/Program mgr noticed expired food located in the food pantry area located in the garage where the facility keeps their food stored (pictures taken). The main refrigerator located in the kitchen had a lock and it was observed unlocked during the visit. According to staff, they do lock the refrigerator at night and staff leaves snacks available in client's dining table. Facility does not handle cash resources.