Facility Evaluation Report

At 10:00 AM on 07/03/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection and was greeted by Staff Member #1 (S1). The LPA identified herself, explained the purpose of the visit, and asked to meet with the Administrator. S1 called the Administrator to notify her of LPA’s arrival and today’s annual inspection. The Administrator arrived at the facility at 10:45 AM. The LPA interviewed the Administrator, who then accompanied the LPA on a tour of the physical plant. The CARE inspection tool was used during this inspection.

This facility is a residential house with four bedrooms and two bathrooms for clients, a living room, a dining room, a kitchen, a laundry room, and two staff rooms. It is licensed to serve 6 non-ambulatory clients, ages 18 to 59 years old. The majority of the clients have lived at the facility long-term. The current census was 5 clients; three clients were present at the time of this visit. There were two staff members on-duty.

RECORDS REVIEW: The LPA requested records for the facility, staff, and residents. The LPA reviewed staff records and confirmed that all staff associated with the facility have a criminal background clearance, including the two staff on-duty during the site visit. The LPA also observed proof of required training and valid First Aid/CPR certificates for these staff. The LPA then reviewed resident records and observed that five out of five had appraisals, signed admission agreements, and physician’s reports. The facility had an emergency and disaster plan that was reviewed by all staff during an in-service held every six months. The LPA observed a log that documented the fire drills that were held on a monthly basis.

This report continues on LIC809-C, page 2.