Facility Evaluation Report

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility unannounced to conduct a annual inspection. LPA met Tyrone Penny, facility administrator and explained the purpose of the visit.

Physical inspection was conducted including the, kitchen, bathrooms, bedrooms, exteriors, and common areas. Facility is clean, the traffic areas are unobstructed and well lit. Kitchen has adequate lockable storage for sharps, toxics, and medications. 2 clients medications were reviewed with thier MARs, the PRNS/Refusals/Destructions are appropritely documented. common areas and exteriors have adquate space for activities. the exterior has a camper type sleeping zone for staff and workshop type staff area. Bathrooms have adequate hardware in good repair. bedrooms have required furniture and furnishings.

Staff records were reviewed for first aid, tb test, recent training, and background clearance. files a re present and up to date. Client records were reviewed, for the tb test, recent medical assessment, ipp, recent si reports. 2 clients P + I were reviewed, one file matching the balance sheet, other file was not updated from yesterday. The other two clients don't have thier monies managed by the facility. Administrator files were reviewed for the hiv training, the administrators certificate, evacuation plan, infection control plan, liability insurance and workers comp. files are present and up to date. Required posters are present on the walls

Smoke/co alarm is functional, fire extinguishers are dated jaunary 7th 2026, water temperature was measured 111.3*f 3 clients were interviewed, 2 staff were interviewed.

A copy of the report was read and given to the administrator. exit interview was conducted. no citations given as part of this visit.