Facility Evaluation Report

09/09/2025 09:45 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with licensee / administrator Ashley Phelps, administrator Collin Harris and house manager Vanessa Deramo and explained the purpose of the visit.

LPA Knight and staff toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) client rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current.

The facility has a lead staff who has been tasked with being the activities director. This staff plans the activities and ensures that the clients who want to participate are participating. The company uses an activities scheduler to track client activities.

Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet. Medications were reviewed.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area, kitchen, and bathrooms were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Food appears to be stored and prepared properly. Facility has required (7) seven day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational. No pools/bodies of water are on premises. Last disaster drill was conducted in August 2025, which was an earthquake drill, the facility has been conducting fire drills monthly.

LPA requested the following documents that need to be updated in the facility file: LIC500 Personnel report, administrator certificate.

In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection. Technical assistance was provided.

Exit interview conducted and copy of report was provided to licensee / administrator Ashley Phelps.