Facility Evaluation Report

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Inspection of this Adult Residential facility and met with Licensee, Janet Kirby & Administrator, Lanette Stankas. Facility is a 2 story building with 5 bedrooms, fire clearance for 3 ambulatory clients. There is currently 1 client in care.

LPA initiated a tour of the facility at 12:20 PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client room was furnished per regulation with adequate lighting. Water temperature at faucets accessible to clients measured within regulation of 105 degrees to 120 degrees F. Extra hygiene products are kept in the cabinet in the bathroom. Extra Linens are stored in the cabinet in the hall closet. Cabinet located under the kitchen sink containing cleaning supplies was locked. Facility has two days of perishable and one week of non-perishable foods for current census. Fire extinguishers were last inspected & recharged 6/5/2025. Smoke detectors with combination carbon monoxide located throughout the facility were tested and operational. At approximately 12:30 Licensee informed C1 stores and takes own medications; although current physician’s assessment states client cannot administer & store own medications. Regulation 80075(k)(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. (see LIC 809-D). Facility conducts disaster drills quarterly with the last being on 4/23/2025. Medication records must be kept for all prescriptions & PRN medications & include; Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications. (see TA LIC 9102).